Provider Demographics
NPI:1790782092
Name:HENGERER, JAMES RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RUSSELL
Last Name:HENGERER
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 1:2849 LINK RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-3217
Mailing Address - Country:US
Mailing Address - Phone:434-384-8745
Mailing Address - Fax:
Practice Address - Street 1:2321 ATHERHOLT RD
Practice Address - Street 2:SUITE B
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2113
Practice Address - Country:US
Practice Address - Phone:434-947-3993
Practice Address - Fax:434-847-2941
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032236207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006590896Medicaid
VA54-04894959OtherFEDERAL TAX ID #
VA006030OtherANTHEM
VA54-04894959OtherFEDERAL TAX ID #
VA006590896Medicaid