Basic Information
Provider Information | |||||||||
NPI: | 1487107447 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEARTLAND MEDICAL CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEARTLAND COMMUNITY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1312 W 6TH ST | ||||||||
Address2: |   | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 660442219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7858417297 | ||||||||
FaxNumber: | 7858560375 | ||||||||
Practice Location | |||||||||
Address1: | 1312 W 6TH ST | ||||||||
Address2: |   | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 660442219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7858417297 | ||||||||
FaxNumber: | 7858560375 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2016 | ||||||||
LastUpdateDate: | 11/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRANSTROM | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7858417297 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | KS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 208000000X |   | KS | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 261QF0400X |   | KS | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 200688980A | 05 | KS |   | MEDICAID | 30003936890001 | 05 | KS |   | MEDICAID |