Provider Demographics
NPI:1295811412
Name:HERCHLINE, MARYLYNN BRODERICK (MD)
Entity type:Individual
Prefix:
First Name:MARYLYNN
Middle Name:BRODERICK
Last Name:HERCHLINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 332
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1185
Mailing Address - Country:US
Mailing Address - Phone:937-832-7337
Mailing Address - Fax:937-832-4817
Practice Address - Street 1:9000 NORTH MAIN STREET
Practice Address - Street 2:SUITE 332
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1185
Practice Address - Country:US
Practice Address - Phone:937-832-7337
Practice Address - Fax:937-832-4817
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350570272080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1220651OtherUNITED HEALTHCARE
0709602OtherBUREAU FOR CHILDREN WITH
311627276032OtherCARESOURCE
OH0709602Medicaid
1220651OtherAETNA
000000037311OtherBLUE CROSS BLUE SHIELD