Provider Demographics
NPI:1386878973
Name:HERITAGE NETWORK PHYSICIAN
Entity type:Organization
Organization Name:HERITAGE NETWORK PHYSICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-282-0917
Mailing Address - Street 1:729 BEDFORD EULESS RD W
Mailing Address - Street 2:SUITE 108
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-3939
Mailing Address - Country:US
Mailing Address - Phone:817-282-0917
Mailing Address - Fax:817-282-7934
Practice Address - Street 1:729 BEDFORD EULESS RD W
Practice Address - Street 2:SUITE 108
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-3939
Practice Address - Country:US
Practice Address - Phone:817-282-0917
Practice Address - Fax:817-282-7934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1757207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104410902Medicaid
TXD97737Medicare UPIN