Provider Demographics
NPI:1598754145
Name:ELLEMBERGER, HERMAN ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:HERMAN
Middle Name:ROY
Last Name:ELLEMBERGER
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 1:5955 ZEAMER AVE
Mailing Address - Street 2:3 MDG, SGOEE
Mailing Address - City:ELMENDORF AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:907-580-5555
Mailing Address - Fax:
Practice Address - Street 1:3 MDG- SGOEE
Practice Address - Street 2:5955 ZEAMER AVE
Practice Address - City:ELMENDORF AFB
Practice Address - State:AK
Practice Address - Zip Code:99506
Practice Address - Country:US
Practice Address - Phone:907-580-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-083393207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine