Provider Demographics
NPI:1316998305
Name:HERITAGE MEDICAL ASSOCIATES, P.A.
Entity type:Organization
Organization Name:HERITAGE MEDICAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WHITELY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-983-2171
Mailing Address - Street 1:11881 SW 47TH TER
Mailing Address - Street 2:
Mailing Address - City:TOWANDA
Mailing Address - State:KS
Mailing Address - Zip Code:67144-9264
Mailing Address - Country:US
Mailing Address - Phone:316-778-2050
Mailing Address - Fax:316-778-2050
Practice Address - Street 1:500 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:KS
Practice Address - Zip Code:66866-1103
Practice Address - Country:US
Practice Address - Phone:620-983-2171
Practice Address - Fax:620-983-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSF88539Medicare UPIN