Basic Information
| Provider Information | |||||||||
| NPI: | 1780098087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEILAND | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2393432301 | ||||||||
| Practice Location | |||||||||
| Address1: | 2780 CLEVELAND AVE STE 709 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339015857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393433831 | ||||||||
| FaxNumber: | 2393432301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME131633 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 021369000 | 05 | FL | MEDICAID |