Provider Demographics
NPI:1942206388
Name:HERGENROEDER, PAUL F (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:F
Last Name:HERGENROEDER
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 1:17876 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-2602
Mailing Address - Country:US
Mailing Address - Phone:216-383-2222
Mailing Address - Fax:216-298-0241
Practice Address - Street 1:17876 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110
Practice Address - Country:US
Practice Address - Phone:216-383-2222
Practice Address - Fax:216-298-0241
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.087486207RH0002X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA140052OtherPA GROUP
PA0159OtherBLUE CROSS
PA1010757980001Medicaid
B40854Medicare UPIN
PA1010757980001Medicaid