Basic Information
| Provider Information | |||||||||
| NPI: | 1659300564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEARTLAND HOSPICE SERVICES LLC | ||||||||
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| OtherOrganizationName: | PROMEDICA HOSPICE (WARRENTON) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | ATTN: DEAN SHIPMAN | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192547841 | ||||||||
| FaxNumber: | 4192526448 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 JERMANTOWN RD | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220304900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032738693 | ||||||||
| FaxNumber: | 7032738694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 04/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525734 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 251G00000X | HSP-0768 | VA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 004910575 | 05 | VA | MEDICAID |