Basic Information
| Provider Information | |||||||||
| NPI: | 1508286626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEINDEL | ||||||||
| FirstName: | BLOSSOM | ||||||||
| MiddleName: | MARIMPIETRI | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3838 MASSILLON RD | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446857964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308355533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3838 MASSILLON RD | ||||||||
| Address2: | |||||||||
| City: | UNIONTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446857964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308355533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34.012411 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 34.012411 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0121949 | 05 | OH | MEDICAID |