Basic Information
Provider Information | |||||||||
NPI: | 1245345610 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEINECK | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20108 VICTORIA CHASE RD | ||||||||
Address2: |   | ||||||||
City: | LAGO VISTA | ||||||||
State: | TX | ||||||||
PostalCode: | 786456311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5035078701 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1700 BRAZOS AVE | ||||||||
Address2: |   | ||||||||
City: | ROCKDALE | ||||||||
State: | TX | ||||||||
PostalCode: | 765672517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124306412 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2006 | ||||||||
LastUpdateDate: | 04/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD23510 | OR | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | Q7204 | TX | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD2016-0139 | NM | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD.34932 | AL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 287063 | 05 | OR |   | MEDICAID |