1538199591 NPI number — KELLI A HERTZ M.D.

Table of content: KELLI A HERTZ M.D. (NPI 1538199591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538199591 NPI number — KELLI A HERTZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERTZ
Provider First Name:
KELLI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1538199591
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3395
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47732-3395
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:
1373 E SR 62
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-801-0856
Provider Business Practice Location Address Fax Number:
812-801-0769
Provider Enumeration Date:
07/04/2006

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: 207V00000X , with the licence number:  01057454 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2442604000 . This is a "PASSPORT ADVANTAGE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50000949 . This is a "PASSPORT KY MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200427150A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 419915P . This is a "SIHO" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00001620 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000291257 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 64069651 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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