Basic Information
| Provider Information | |||||||||
| NPI: | 1194931428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEUERMANN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BC-HIS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163132800 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 WARD PKWY | ||||||||
| Address2: | SUITE 2080 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641142614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164444547 | ||||||||
| FaxNumber: | 8164442892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 07/01/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 948 | MO | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237700000X | 889 | KS | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 36832026 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 335699609 | 05 | MO | MEDICAID | 345699607 | 01 | MO | FAMILY HEALTH PARTNERS | OTHER |