Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | CH045760 | MI |
NPI | 1013004373 |
---|---|
Provider Name | Clare B Heidtke |
First Address | Petoskey, MI 49770-8421 |
Second Address | Petoskey, MI 49770-8421 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
045760 | BLUE CROSS BLUE SHEILD MI (01) | MI |
3509689 | (05) | MI |
E00453 | (02) | MI |