Basic Information
| Provider Information | |||||||||
| NPI: | 1376188391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEARTLAND FAMILY MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 W VAN DORN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622743212 | ||||||||
| FaxNumber: | 6622743213 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W VAN DORN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622743212 | ||||||||
| FaxNumber: | 6622743213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6622743212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 04274797 | 05 | MS | MEDICAID |