Provider Demographics
NPI:1538193602
Name:HEARTLAND DERMATOLOGY
Entity type:Organization
Organization Name:HEARTLAND DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WHITCROFT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-882-4129
Mailing Address - Street 1:200 E HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201
Mailing Address - Country:US
Mailing Address - Phone:605-882-3343
Mailing Address - Fax:605-882-4167
Practice Address - Street 1:200 E HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:605-882-3343
Practice Address - Fax:605-882-4167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S5396Medicare ID - Type Unspecified