Provider Demographics
NPI:1134147325
Name:HERTWECK, SUSAN P (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:HERTWECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:PAIGE
Other - Last Name:HERTWECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 766351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3991 DUTCHMANS LN STE 303
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4723
Practice Address - Country:US
Practice Address - Phone:502-559-1750
Practice Address - Fax:502-666-7707
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252392080A0000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100332440Medicaid
KY1049243OtherPASSPORT SPECIALITY - FOUNDATION
KY000000047600OtherANTHEM - FOUNDATION
KY64252398Medicaid
KY1049273OtherPASSPORT SPECIALITY - PSC
KYK027510OtherMEDICARE PTAN
KY1049241OtherPASSPORT PCP# - FOUNDATION
KY50034184OtherPASSPORT & PASSPORT ADVTG
KY000000045416OtherANTHEM - PSC
KY1049243OtherPASSPORT SPECIALITY - FOUNDATION
KY1275731Medicare ID - Type Unspecified
KY1049241OtherPASSPORT PCP# - FOUNDATION