MEDICARE: MR. DONALD GARY HEACOCK P.T.

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	225100000X	Physical Therapist	15332	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	756LN288	OTHER	MD	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	147433401	OTHER	MD	ACS / US DEPT OF LABOR
3	1359660	OTHER	MD	AETNA USHEALTHCARE
4	145799600	OTHER	MD	OWCP/DEPARTMENT OF LABOR
5	1784629	OTHER	MD	UNITED HEALTHCARE
6	521200786	OTHER	MD	UNITED HEALTH CARE

General Provider Information

NPI Number	:	1023022324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD GARY HEACOCK P.T.

Provider Business Mailing Address
First Line	:	350 NEW FIDELITY CT
Second Line	:
City	:	GARNER
State	:	NC
Zip	:	27529-2665
Country	:	US
Telephone Number	:	919-258-2714
Fax Number	:	410-648-4878

Provider Business Practice Location Address
First Line	:	7310 RITCHIE HWY
Second Line	:	SUITE 500
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-3065
Country	:	US
Telephone Number	:	410-766-4435
Fax Number	:	410-766-4437

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

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	05/07/2020

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