1962485029 NPI number — ERICA LYNDRUP HERZOG MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962485029 NPI number — ERICA LYNDRUP HERZOG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERZOG
Provider First Name:
ERICA
Provider Middle Name:
LYNDRUP
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1962485029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 GEORGE STREET
Provider Second Line Business Mailing Address:
6TH FLOOR PO BOX 9805
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06536-0805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
789 HOWARD AVE
Provider Second Line Business Practice Location Address:
WINCHESTER CHEST CLINIC - FITKIN BUILDING - 2ND FLOOR
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-785-4198
Provider Business Practice Location Address Fax Number:
203-785-3826
Provider Enumeration Date:
11/22/2005

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: 207RC0200X , with the licence number:  039625 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 039625 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001396250 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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