Provider Demographics
NPI:1013154160
Name:JOSEPH G HERRMANN MD LLC
Entity Type:Organization
Organization Name:JOSEPH G HERRMANN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LICAVOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-0056
Mailing Address - Street 1:1922 DREXEL HILL CT
Mailing Address - Street 2:
Mailing Address - City:DES PERES
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3647
Mailing Address - Country:US
Mailing Address - Phone:314-432-0056
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 419A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-432-0056
Practice Address - Fax:314-432-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103604174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO922094568Medicare PIN