Basic Information
| Provider Information | |||||||||
| NPI: | 1568422004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIBERGER | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | JOE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26067 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841260067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396240400 | ||||||||
| FaxNumber: | 2396240401 | ||||||||
| Practice Location | |||||||||
| Address1: | 7717 COLLIER BLVD UNIT 100 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341142872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396248220 | ||||||||
| FaxNumber: | 2396248221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME150308 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 112651100 | 05 | FL | MEDICAID | KW5LU | 01 | FL | BCBS | OTHER |