Provider Demographics
NPI:1962705202
Name:HERITAGE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:HERITAGE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIPPERER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:907-232-8545
Mailing Address - Street 1:501 N KNIK ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7050
Mailing Address - Country:US
Mailing Address - Phone:907-232-8545
Mailing Address - Fax:
Practice Address - Street 1:501 N KNIK ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7050
Practice Address - Country:US
Practice Address - Phone:907-232-8545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty