Provider Demographics
NPI:1396993895
Name:CLARE B. HEIDTKE, MD, PLLC
Entity type:Organization
Organization Name:CLARE B. HEIDTKE, MD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLARE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HEIDTKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-487-0970
Mailing Address - Street 1:2810 CHARLEVOIX AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8421
Mailing Address - Country:US
Mailing Address - Phone:231-487-0970
Mailing Address - Fax:231-487-0979
Practice Address - Street 1:2810 CHARLEVOIX AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8421
Practice Address - Country:US
Practice Address - Phone:231-487-0970
Practice Address - Fax:231-487-0979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICH045760207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3509689Medicaid