Provider Demographics
NPI:1073557500
Name:HERGENROTHER, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:HERGENROTHER
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 1:2123 AUBURN AVE
Mailing Address - Street 2:#404
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-241-5630
Mailing Address - Fax:513-241-7146
Practice Address - Street 1:2123 AUBURN AVE
Practice Address - Street 2:#404
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-241-5630
Practice Address - Fax:513-241-7146
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-5061207RN0300X
KY37649207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2330203Medicaid
KY64054018Medicaid
OH390008623OtherMEDICARE RAILROAD
KY64054018Medicaid
OH2330203Medicaid
OHH58417Medicare UPIN