Provider Demographics
NPI:1053413740
Name:HEARTLAND PEDIATRIC CLINIC
Entity type:Organization
Organization Name:HEARTLAND PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-993-5274
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8066
Mailing Address - Country:US
Mailing Address - Phone:618-993-5274
Mailing Address - Fax:618-993-0639
Practice Address - Street 1:1000 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1630
Practice Address - Country:US
Practice Address - Phone:618-993-5274
Practice Address - Fax:618-999-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL14-8966Medicare ID - Type Unspecified