Provider Demographics
NPI:1326016726
Name:HERGAN, EDITH (MD)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:HERGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 CROMWELL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-1800
Mailing Address - Country:US
Mailing Address - Phone:847-477-3809
Mailing Address - Fax:847-477-3809
Practice Address - Street 1:546 CROMWELL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1800
Practice Address - Country:US
Practice Address - Phone:847-477-3809
Practice Address - Fax:847-477-3809
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082560207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082560Medicaid
ILK08856Medicare ID - Type Unspecified
ILF53954Medicare UPIN