Provider Demographics
NPI:1962405787
Name:HEISE, JOHN GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GEORGE
Last Name:HEISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2101
Mailing Address - Country:US
Mailing Address - Phone:423-778-5437
Mailing Address - Fax:423-778-7507
Practice Address - Street 1:900 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2101
Practice Address - Country:US
Practice Address - Phone:423-778-5437
Practice Address - Fax:423-778-7507
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD256942080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ005887Medicaid
TN3896392Medicaid
VA010100704Medicaid
0281780003Medicare PIN
TN30834841Medicare PIN
TN103I086169Medicare UPIN
TN3700592Medicare PIN
0281780001Medicare PIN
TN3896392Medicare PIN