Provider Demographics
NPI:1144546870
Name:HEIDEMAN, PAUL P (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:P
Last Name:HEIDEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:252 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105
Practice Address - Country:US
Practice Address - Phone:262-767-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI638172085R0202X, 2085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIENROLLEDMedicaid
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MN300006240Medicare PIN
IAENROLLEDMedicaid