Provider Demographics
NPI:1023249919
Name:HERITAGE NETWORK PHYSICIAN
Entity type:Organization
Organization Name:HERITAGE NETWORK PHYSICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:682-626-5488
Mailing Address - Street 1:800 MOUNTAIN TER
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-4210
Mailing Address - Country:US
Mailing Address - Phone:682-626-5488
Mailing Address - Fax:817-665-2974
Practice Address - Street 1:800 MOUNTAIN TER
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-4210
Practice Address - Country:US
Practice Address - Phone:682-626-5488
Practice Address - Fax:817-665-2974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1757207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX881511Medicaid
TX881511Medicaid