Basic Information
| Provider Information | |||||||||
| NPI: | 1902062219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEASER | ||||||||
| FirstName: | AMITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MUKHERJEE | ||||||||
| OtherFirstName: | AMITA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D, | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 17025 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729177025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792742000 | ||||||||
| FaxNumber: | 4792742194 | ||||||||
| Practice Location | |||||||||
| Address1: | 6801 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729034067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792744100 | ||||||||
| FaxNumber: | 4792744199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-127885 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 125054221 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | E9240 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5BA25 | 01 | AR | ARKANSAS BLUECROSS BLUE SHIELD | OTHER | 036127885 | 05 | IL | MEDICAID | 04515143 | 01 | IL | BCBS# | OTHER |