Basic Information
| Provider Information | |||||||||
| NPI: | 1760513154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIDENREICH | ||||||||
| FirstName: | JENS | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21249 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402210249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025811500 | ||||||||
| FaxNumber: | 5025404959 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 S JACKSON ST | ||||||||
| Address2: | C07 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525875 | ||||||||
| FaxNumber: | 5028521754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 03/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | FL 019 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7100052110 | 05 | KY | MEDICAID |