1962654806 NPI number — BJORN S HERMAN MD

Table of content: BJORN S HERMAN MD (NPI 1962654806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962654806 NPI number — BJORN S HERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERMAN
Provider First Name:
BJORN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1962654806
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 JACKSON PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLIPOLIS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45631-1560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-589-3100
Provider Business Mailing Address Fax Number:
740-589-3123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 PGA BLVD STE 450
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-2841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-219-4400
Provider Business Practice Location Address Fax Number:
561-219-4401
Provider Enumeration Date:
10/22/2008

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: 207Y00000X , with the licence number:  ME120761 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000495011 . This is a "OH MEDICAID UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 310917085299 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0068169 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810023527 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 014100100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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