Basic Information
| Provider Information | |||||||||
| NPI: | 1942203104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEATH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2229 MARY SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122684017 | ||||||||
| Practice Location | |||||||||
| Address1: | 2229 MARY SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478827633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122683318 | ||||||||
| FaxNumber: | 8122684017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01049035A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200015680A | 05 | IN | MEDICAID | 200219540A | 05 | IN | MEDICAID |