MEDICARE: CLARE B HEIDTKE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	CH045760	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	045760	OTHER	MI	BLUE CROSS BLUE SHEILD MI

General Provider Information

NPI Number	:	1013004373
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARE B HEIDTKE M.D.

Provider Business Mailing Address
First Line	:	2810 CHARLEVOIX AVE
Second Line	:	SUITE 104
City	:	PETOSKEY
State	:	MI
Zip	:	49770-8421
Country	:	US
Telephone Number	:	231-487-0970
Fax Number	:	231-487-0979

Provider Business Practice Location Address
First Line	:	2810 CHARLEVOIX AVE
Second Line	:	SUITE 104
City	:	PETOSKEY
State	:	MI
Zip	:	49770-8421
Country	:	US
Telephone Number	:	231-487-0970
Fax Number	:	231-487-0979

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/08/2007

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