Provider Demographics
NPI:1548272289
Name:HEISE, JEFFREY A (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
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:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-0129
Mailing Address - Country:US
Mailing Address - Phone:317-468-6270
Mailing Address - Fax:317-468-6268
Practice Address - Street 1:801 N STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1270
Practice Address - Country:US
Practice Address - Phone:317-462-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062448A208600000X
IN43010802532086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200841490Medicaid
IN200941580AMedicaid
IN1114016987OtherNPI NUMBER FOR HANCOCK REGIONAL PHYSICIAN GROUP
IN000000493483OtherANTHEM PIN#
IN7612847OtherAETNA PIN#
IN7612847OtherAETNA PIN#
INI68320Medicare UPIN
IN200841490Medicaid