Provider Demographics
NPI:1487107447
Name:HEARTLAND MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:HEARTLAND MEDICAL CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-841-7297
Mailing Address - Street 1:1312 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2219
Mailing Address - Country:US
Mailing Address - Phone:785-841-7297
Mailing Address - Fax:785-856-0375
Practice Address - Street 1:1312 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2219
Practice Address - Country:US
Practice Address - Phone:785-841-7297
Practice Address - Fax:785-856-0375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS207Q00000X, 208000000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200688980AMedicaid
KS30003936890001Medicaid
KS200688980AMedicaid