Provider Demographics
NPI:1518262096
Name:JON C. HERBENER, M.D.,P.C.
Entity Type:Organization
Organization Name:JON C. HERBENER, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERBENER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-437-5385
Mailing Address - Street 1:187 S HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-2069
Mailing Address - Country:US
Mailing Address - Phone:517-437-5385
Mailing Address - Fax:571-439-0945
Practice Address - Street 1:187 S HOWELL ST
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-2069
Practice Address - Country:US
Practice Address - Phone:517-437-5385
Practice Address - Fax:571-439-0945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJH033911174400000X
MI5101018596174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1089530-TYPE 10Medicaid