Provider Demographics
NPI:1144241134
Name:HEARTLAND PEDIATRICS ASSOCIATION OF WAUCHULA, P.A.
Entity type:Organization
Organization Name:HEARTLAND PEDIATRICS ASSOCIATION OF WAUCHULA, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:APURBA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-767-1414
Mailing Address - Street 1:120 HEARTLAND WAY
Mailing Address - Street 2:
Mailing Address - City:WAUCHULA
Mailing Address - State:FL
Mailing Address - Zip Code:33873-5000
Mailing Address - Country:US
Mailing Address - Phone:863-767-1414
Mailing Address - Fax:863-767-1763
Practice Address - Street 1:120 HEARTLAND WAY
Practice Address - Street 2:
Practice Address - City:WAUCHULA
Practice Address - State:FL
Practice Address - Zip Code:33873-5000
Practice Address - Country:US
Practice Address - Phone:863-767-1414
Practice Address - Fax:863-767-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
FLME72938208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33881OtherBLUECROSS BLUE SHIELD OF FLORIDA
FL660018201Medicaid
FL054605402Medicaid
FL660018201RMedicaid
FL660018201Medicaid