Provider Demographics
NPI:1962896027
Name:HERITAGE PHYSICIAN AND RESOURCE GROUP LLC
Entity type:Organization
Organization Name:HERITAGE PHYSICIAN AND RESOURCE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONNY
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-238-0088
Mailing Address - Street 1:1009 W QUINN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2425
Mailing Address - Country:US
Mailing Address - Phone:208-238-0088
Mailing Address - Fax:208-238-0055
Practice Address - Street 1:1009 W QUINN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-2425
Practice Address - Country:US
Practice Address - Phone:208-238-0088
Practice Address - Fax:208-238-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty