Provider Demographics
NPI:1538354964
Name:JACK HEETHOUSE DO PLLC
Entity type:Organization
Organization Name:JACK HEETHOUSE DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:W
Authorized Official - Last Name:HEETHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-722-7245
Mailing Address - Street 1:1675 LEAHY ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5500
Mailing Address - Country:US
Mailing Address - Phone:231-722-7245
Mailing Address - Fax:231-722-6103
Practice Address - Street 1:1675 LEAHY ST
Practice Address - Street 2:SUITE 120
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-722-7245
Practice Address - Fax:231-722-6103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012999207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4308380Medicaid
MI4308380Medicaid
MIN30160001Medicare PIN