Provider Demographics
NPI:1891029880
Name:HERINGHAUS, GRETCHEN M (AA)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:M
Last Name:HERINGHAUS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 SILVER FALLS ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-7847
Mailing Address - Country:US
Mailing Address - Phone:419-236-1868
Mailing Address - Fax:614-583-3300
Practice Address - Street 1:500 S CLEVELAND AVE
Practice Address - Street 2:ANESTHESIA DEPT/COA
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8971
Practice Address - Country:US
Practice Address - Phone:614-898-6659
Practice Address - Fax:614-898-8631
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67.000192367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0078670Medicaid
OHXXXXX8807-00OtherOHIO BWC
OH000000806012OtherANTHEM OHIO
OH0078670Medicaid