Basic Information
| Provider Information | |||||||||
| NPI: | 1811995715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEAFNER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043761605 | ||||||||
| FaxNumber: | 7043358448 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 BALDWIN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282043109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043761605 | ||||||||
| FaxNumber: | 7043358448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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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 | 207T00000X | 38354 | NC | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 140004696 | 01 | RAILROAD MEDICARE | OTHER | N04785 | 05 | SC | MEDICAID | 8940834 | 05 | NC | MEDICAID |