Provider Demographics
NPI:1053534784
Name:HEARTLAND HEALTH OUTREACH
Entity type:Organization
Organization Name:HEARTLAND HEALTH OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIEDD NURSE MIDWIFE
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:RIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:773-575-2586
Mailing Address - Street 1:1348 N ARTESIAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4998
Mailing Address - Country:US
Mailing Address - Phone:773-227-6282
Mailing Address - Fax:
Practice Address - Street 1:1015 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5017
Practice Address - Country:US
Practice Address - Phone:773-275-2586
Practice Address - Fax:773-275-3689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health