1194756387 NPI number — DWIGHT B HERMAN CRNA

Table of content: DWIGHT B HERMAN CRNA (NPI 1194756387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194756387 NPI number — DWIGHT B HERMAN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERMAN
Provider First Name:
DWIGHT
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194756387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 W HOUSTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERMAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75090-5909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-891-7000
Provider Business Mailing Address Fax Number:
903-813-1479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERMAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75092-7354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-870-4494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  700502 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 165451903/165451904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 165451902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00220867 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 89509U . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 84813U . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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