Basic Information
Provider Information | |||||||||
NPI: | 1801840046 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEARTLAND HOSPICE SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROMEDICA HOSPICE (DAYTON) | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 580 LINCOLN PARK BLVD | ||||||||
Address2: | SUITE 320 | ||||||||
City: | KETTERING | ||||||||
State: | OH | ||||||||
PostalCode: | 454293493 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372996980 | ||||||||
FaxNumber: | 9372936399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2006 | ||||||||
LastUpdateDate: | 04/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLEN | ||||||||
AuthorizedOfficialFirstName: | MARTIN | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4192525734 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 0121-HSP | OH | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 2114983 | 05 | OH |   | MEDICAID |