Basic Information
| Provider Information | |||||||||
| NPI: | 1548752041 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HERITAGE NEUROLOGY PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4849 N MESA ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799125919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153516600 | ||||||||
| FaxNumber: | 9153516600 | ||||||||
| Practice Location | |||||||||
| Address1: | 2270 JOE BATTLE BLVD STE Q | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799382610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153171500 | ||||||||
| FaxNumber: | 9152015101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2018 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENSON | ||||||||
| AuthorizedOfficialFirstName: | OLAJIDE | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7135055358 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A2900X | Q9956 | TX | Y | 193400000X SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 3883670-01 | 05 | TX | MEDICAID |