Provider Demographics
NPI:1417401787
Name:HERTOG, BETHANY
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:
Last Name:HERTOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 E VERMONT ST
Mailing Address - Street 2:STE 110
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3685
Mailing Address - Country:US
Mailing Address - Phone:317-559-0950
Mailing Address - Fax:
Practice Address - Street 1:429 E VERMONT ST
Practice Address - Street 2:STE 110
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3685
Practice Address - Country:US
Practice Address - Phone:317-559-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28170125A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily