Provider Demographics
NPI:1164629515
Name:HERPICH, BYRON KENDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:KENDALL
Last Name:HERPICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-2869
Mailing Address - Fax:601-815-9356
Practice Address - Street 1:5200 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8013
Practice Address - Country:US
Practice Address - Phone:651-982-7000
Practice Address - Fax:651-982-7110
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036158477207R00000X
LAMD.204283207R00000X
FLTRN11509207R00000X
MS21044207R00000X
FLME105030207R00000X
TXU5862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01276718Medicaid
MS8940397Medicaid
MS395851YJ5DMedicare PIN
FLDM172ZMedicare PIN
MS8940397Medicaid