MEDICARE: DR. KEVIN A HEINTZELMAN DO

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	207R00000X	Internal Medicine Physician	224633	NY
2	207R00000X	Internal Medicine Physician	20864	MS

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184701344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN A HEINTZELMAN DO

Provider Business Mailing Address
First Line	:	PO BOX 23996
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39225
Country	:	US
Telephone Number	:	601-206-6100
Fax Number	:	601-206-6052

Provider Business Practice Location Address
First Line	:	1200 N STATE ST
Second Line	:	SUITE 480
City	:	JACKSON
State	:	MS
Zip	:	39202-2001
Country	:	US
Telephone Number	:	601-352-2273
Fax Number	:	601-714-3415

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	06/06/2013

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