Provider Demographics
NPI:1215081773
Name:HEINEY, JAKE P (MD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:P
Last Name:HEINEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7640 SYLVANIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9263
Mailing Address - Country:US
Mailing Address - Phone:419-517-7533
Mailing Address - Fax:419-517-7502
Practice Address - Street 1:7640 SYLVANIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-9729
Practice Address - Country:US
Practice Address - Phone:419-517-7533
Practice Address - Fax:419-517-7502
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97334207X00000X
OH35.090990207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000559947OtherANTHEM
OH2817723Medicaid
9873118OtherAETNA
OHP00820608OtherRRMC
05382OtherPHC
$$$$$$$$$-003OtherMMO
OH2817723Medicaid
OH$$$$$$$$$-00OtherBWC