Individual
KELLY BETH HEIDLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.O.
Contact information
Practice address
6308 8TH AVE, KENOSHA, WI 53143-5031
(414) 290-6720
(414) 290-6755
Mailing address
111 E WISCONSIN AVE STE 2000, MILWAUKEE, WI 53202-4809
(414) 290-6720
(414) 290-6755
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
67122-21
WI
207R00000X
Internal Medicine Physician
OS018162
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003403181
HIGHMARK BCBS
PA
01
—
0182229
OHIO MEDICAID
PA
05
—
1031239290001
—
PA
Enumeration date
02/12/2013
Last updated
12/28/2021
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