Provider Demographics
NPI:1215933346
Name:HEEERS, PA
Entity type:Organization
Organization Name:HEEERS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HURSIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS-SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-373-2940
Mailing Address - Street 1:1814 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3410
Mailing Address - Country:US
Mailing Address - Phone:601-373-2940
Mailing Address - Fax:601-373-2720
Practice Address - Street 1:1814 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3410
Practice Address - Country:US
Practice Address - Phone:601-373-2940
Practice Address - Fax:601-373-2720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13888261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08236531Medicaid
MS00112110Medicaid
MSF65463Medicare UPIN
MSC02914Medicare ID - Type Unspecified
MS080003184Medicare ID - Type UnspecifiedHURSIE DAVIS-SULLIVAN