Basic Information
| Provider Information | |||||||||
| NPI: | 1376165977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEITHAUS | ||||||||
| FirstName: | SETH | ||||||||
| MiddleName: | ALEXANDER KIRSCH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2510 N MURRAY AVE APT 107 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532113919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652479836 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3333 GREEN BAY RD | ||||||||
| Address2: | |||||||||
| City: | NORTH CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600643037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475783000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2020 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125.076247 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.