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NPI Code Detail

MEDICARE: HEARTLAND INTERNATIONAL HEALTH CENTER

MEDICARE: HEARTLAND INTERNATIONAL HEALTH CENTER
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
11223G0001XGeneral Practice Dentistry003IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1103527OTHERILDORAL DENTAL

General Provider Information

NPI Number : 1790942084
Entity Type Code : Organization
Provider Name (Legal Business Name) : HEARTLAND INTERNATIONAL HEALTH CENTER
Provider Business Mailing Address
First Line : 3048 N. WILTON AVE
Second Line : 2ND FLOOR
City : CHICAGO
State : IL
Zip : 60657-6710
Country : US
Telephone Number : 773-296-7544
Fax Number : 773-751-4175
Provider Business Practice Location Address
First Line : 845 W WILSON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60640-5704
Country : US
Telephone Number : 773-728-7264
Fax Number : 773-728-7557
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : GWENN RAUSCH
Credential :
Telephone Number : 773-296-7589
Provider Enumeration Date : 05/22/2008
Last Update Date : 09/20/2010

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Directions to “HEARTLAND INTERNATIONAL HEALTH CENTER ” Practice Location

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