Basic Information
Provider Information | |||||||||
NPI: | 1023061686 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEARTLAND HOSPICE SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROMEDICA HOSPICE (INDIANAPOLIS) | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 333 N SUMMIT ST | ||||||||
Address2: | ATTN: DEAN SHIPMAN | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436042615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4192547841 | ||||||||
FaxNumber: | 4192526448 | ||||||||
Practice Location | |||||||||
Address1: | 931 E 86TH ST | ||||||||
Address2: | SUITE 208 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462401852 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3172513012 | ||||||||
FaxNumber: | 3172513016 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 01/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLEN | ||||||||
AuthorizedOfficialFirstName: | MARTIN | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4192525734 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/23/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 07-003154-1 | IN | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 200142900(B) | 05 | IN |   | MEDICAID |