=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619952561
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN D. HEIM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2005
-----------------------------------------------------
Last Update Date | 10/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3562 RIDGE PARK DR SUITE A
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-668-7878
-----------------------------------------------------
Fax | 330-668-4747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3562 RIDGE PARK DR SUITE A
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-668-7878
-----------------------------------------------------
Fax | 330-668-4747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 35071122
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------