Basic Information
| Provider Information | |||||||||
| NPI: | 1265753610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEINSELMAN | ||||||||
| FirstName: | HALSEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745233161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745233161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2010 | ||||||||
| LastUpdateDate: | 12/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 01072978 | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000825936 | 01 | IN | ANTHEM | OTHER | 201183800 | 05 | IN | MEDICAID |