Provider Demographics
NPI:1316049547
Name:HEARTLAND OTOLARYNGOLOGY LLC
Entity type:Organization
Organization Name:HEARTLAND OTOLARYNGOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-518-1810
Mailing Address - Street 1:1172 CYPRESS GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7560
Mailing Address - Country:US
Mailing Address - Phone:407-518-1810
Mailing Address - Fax:407-201-8834
Practice Address - Street 1:1172 CYPRESS GLEN CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7560
Practice Address - Country:US
Practice Address - Phone:407-518-1810
Practice Address - Fax:407-201-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0058319207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064221500Medicaid
FL064221500Medicaid
11246AMedicare ID - Type Unspecified