Basic Information
Provider Information | |||||||||
NPI: | 1457349680 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEUMAN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | DAVID | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1330 COSHOCTON AVE | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | OH | ||||||||
PostalCode: | 430501440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403939000 | ||||||||
FaxNumber: | 7403920167 | ||||||||
Practice Location | |||||||||
Address1: | 1330 COSHOCTON AVE | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | OH | ||||||||
PostalCode: | 430501440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403939000 | ||||||||
FaxNumber: | 7403920167 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2005 | ||||||||
LastUpdateDate: | 03/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 44608 | TN | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 051144 | GA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 35123548 | OH | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 01307453 | 01 | TN | AMERIGROUP | OTHER | 7100114270 | 05 | KY |   | MEDICAID | 1514519 | 05 | TN |   | MEDICAID | 4233685 | 01 | TN | BCBS | OTHER | 203500913010 | 01 | TN | TRICARE NORTH | OTHER |