Provider Demographics
NPI:1811983729
Name:HERGENROEDER, PATRICK THOMAS (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:THOMAS
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 1:34 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-3026
Mailing Address - Country:US
Mailing Address - Phone:440-247-2644
Mailing Address - Fax:440-247-0131
Practice Address - Street 1:34 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-3026
Practice Address - Country:US
Practice Address - Phone:440-247-2644
Practice Address - Fax:440-247-0131
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-038239174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0295845Medicaid
OHA75513Medicare UPIN
OH0295845Medicaid