Basic Information
| Provider Information | |||||||||
| NPI: | 1790704401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEITZMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | CENTRAL VERMONT MEDICAL CENTER-FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022255660 | ||||||||
| FaxNumber: | 8022299533 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | MOB-A SUITE 2-1 | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056029516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022255660 | ||||||||
| FaxNumber: | 8022292533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 12/04/2014 | ||||||||
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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 | 207RI0011X | 420006618 | VT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 042.0006618 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0005341 | 05 | VT | MEDICAID | P01125405 | 01 | VT | RAILROAD MEDICARE LINKED TO CVMC MGP | OTHER | 060014973 | 01 | VT | RAIL ROAD MEDICARE | OTHER |