Provider Demographics
NPI:1730166430
Name:HEICHBERGER, LISA E (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:E
Last Name:HEICHBERGER
Suffix:
Gender:F
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:803-435-5270
Mailing Address - Fax:803-433-0154
Practice Address - Street 1:50 E HOSPITAL ST STE 4
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-435-8828
Practice Address - Fax:803-435-2239
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23284207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT73934Medicaid
SC5944657OtherCIGNA
SC080185243OtherRAILROAD MEDICARE
SCT73934Medicaid
H44998Medicare UPIN