Provider Demographics
NPI:1033387865
Name:HEATHROW INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:HEATHROW INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP VP OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:TEDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-333-2273
Mailing Address - Street 1:4106 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3315
Mailing Address - Country:US
Mailing Address - Phone:407-333-2273
Mailing Address - Fax:407-333-3939
Practice Address - Street 1:4106 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3315
Practice Address - Country:US
Practice Address - Phone:407-333-2273
Practice Address - Fax:407-333-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000617400Medicaid
FL307909100Medicaid
FLAM199OtherMEDICARE PTAN
FLPTAN DN9084OtherMEDICARE RAILROAD