Active NPI
Heritage Physician and Resource Group LLC
- General Practice Physician
- Pocatello, ID
National Provider Identifier
1962896027
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Physician
- Legal business name
- HERITAGE PHYSICIAN AND RESOURCE GROUP LLC
- Practice address
- 1009 W Quinn Rd
Pocatello, ID 83202-2425 - Phone
- (208) 238-0088
- Fax
- (208) 238-0055
- NPI assigned
- Mar 26, 2015
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Jonny Ryan Fisher
- Title
- Ceo
- Phone
- (208) 238-0088
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | |||
| General Practice Physician | 208D00000X | Primary |
Addresses
Primary practice location
1009 W Quinn Rd
Pocatello, ID 83202-2425
Mailing address
1009 W Quinn Rd
Pocatello, ID 83202-2425
Phone (208) 238-0088
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ID
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20151222001048 | ID | Part B Supplier - Clinic/Group Practice | 0244531986 |
Receives reassigned benefits from 3 practitioners Practice locations: Pocatello, ID |
National Provider Directory
National Provider DirectoryLocations
140 N Union Ave
Ste F350
Farmington, UT 84025
140 N Union Ave
Ste 350
Farmington, UT 84025
Phone (801) 298-1100
Practitioners & affiliated clinicians
Practitioners 3
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1427328000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1723680000000",
"number": "1962896027",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1009 W QUINN RD",
"city": "POCATELLO",
"state": "ID",
"postal_code": "832022425",
"telephone_number": "208-238-0088",
"fax_number": "208-238-0055"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1009 W QUINN RD",
"city": "POCATELLO",
"state": "ID",
"postal_code": "832022425",
"telephone_number": "208-238-0088",
"fax_number": "208-238-0055"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "HERITAGE PHYSICIAN AND RESOURCE GROUP LLC",
"organizational_subpart": "NO",
"enumeration_date": "2015-03-26",
"last_updated": "2024-08-15",
"certification_date": "2024-08-15",
"status": "A",
"authorized_official_last_name": "FISHER",
"authorized_official_first_name": "JONNY",
"authorized_official_middle_name": "RYAN",
"authorized_official_title_or_position": "CEO",
"authorized_official_telephone_number": "208-238-0088"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Social Worker, Clinical",
"state": null,
"license": null,
"primary": false
},
{
"code": "208D00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "General Practice",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pocatello, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.