Provider Demographics
NPI:1821203969
Name:HERLIHY CLINIC P.C.
Entity Type:Organization
Organization Name:HERLIHY CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HERLIHY,
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:817-442-0200
Mailing Address - Street 1:1695 E SOUTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6424
Mailing Address - Country:US
Mailing Address - Phone:817-442-0200
Mailing Address - Fax:817-442-0204
Practice Address - Street 1:1695 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6424
Practice Address - Country:US
Practice Address - Phone:817-442-0200
Practice Address - Fax:817-442-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C75809Medicare UPIN
AL000009927Medicare ID - Type UnspecifiedAL MEDICARE #
TX00W410Medicare ID - Type UnspecifiedTEXAS MEDICARE GROUP #
TX8F2793Medicare ID - Type UnspecifiedTEXAS INDIVIDUAL #
MS260000571Medicare ID - Type UnspecifiedMS MEDICARE #