Basic Information
| Provider Information | |||||||||
| NPI: | 1013176312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEIKS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3916 N INTERTECH CT | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549136957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209961000 | ||||||||
| FaxNumber: | 9209961054 | ||||||||
| Practice Location | |||||||||
| Address1: | 3916 N INTERTECH CT | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549136957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209961000 | ||||||||
| FaxNumber: | 9209961054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 05/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35097870 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54556-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1013176312 | 05 | WI | MEDICAID |