Provider Demographics
NPI:1215107206
Name:OSTEOPATHIC HERITAGE, P.A.
Entity type:Organization
Organization Name:OSTEOPATHIC HERITAGE, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-666-6950
Mailing Address - Street 1:8246 RIVER COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:WEEKI WACHEE
Mailing Address - State:FL
Mailing Address - Zip Code:34607-2101
Mailing Address - Country:US
Mailing Address - Phone:352-684-8637
Mailing Address - Fax:352-684-8638
Practice Address - Street 1:8246 RIVER COUNTRY DR
Practice Address - Street 2:
Practice Address - City:WEEKI WACHEE
Practice Address - State:FL
Practice Address - Zip Code:34607-2101
Practice Address - Country:US
Practice Address - Phone:352-684-8637
Practice Address - Fax:352-684-8638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6098207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7182Medicare PIN
FLAJ160Medicare UPIN