Provider Demographics
NPI:1730230210
Name:HERITAGE RADIOLOGY, PC
Entity type:Organization
Organization Name:HERITAGE RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-942-1674
Mailing Address - Street 1:195 MYERS AVE
Mailing Address - Street 2:P.O. BOX 128
Mailing Address - City:GUILD
Mailing Address - State:TN
Mailing Address - Zip Code:37340-3099
Mailing Address - Country:US
Mailing Address - Phone:423-942-1674
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 28
Practice Address - Street 2:GRANDVIEW MEDICAL CENTER
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3638
Practice Address - Country:US
Practice Address - Phone:423-837-3423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729274Medicaid
TN3729274Medicaid