=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598944589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES E. HETH, D.O., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2007
-----------------------------------------------------
Last Update Date | 10/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42855 GARFIELD RD STE 105
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-5027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-226-1387
-----------------------------------------------------
Fax | 586-226-1859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42855 GARFIELD RD STE 105
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48038-5027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-226-1387
-----------------------------------------------------
Fax | 586-226-1859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | DIANA GARFIELD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-226-1490
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101009233
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------