Basic Information
| Provider Information | |||||||||
| NPI: | 1730166430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEICHBERGER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3239 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295023239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034355270 | ||||||||
| FaxNumber: | 8034330154 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 E HOSPITAL ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | MANNING | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291023149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034358828 | ||||||||
| FaxNumber: | 8034352239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23284 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | T73934 | 05 | SC | MEDICAID | 5944657 | 01 | SC | CIGNA | OTHER | 080185243 | 01 | SC | RAILROAD MEDICARE | OTHER |