Provider Demographics
NPI:1124171293
Name:PAUL J. HERGENROEDER, M.D., LTD
Entity type:Organization
Organization Name:PAUL J. HERGENROEDER, M.D., LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HERGENROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-523-6728
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-0039
Mailing Address - Country:US
Mailing Address - Phone:870-523-6728
Mailing Address - Fax:
Practice Address - Street 1:2000 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-3661
Practice Address - Country:US
Practice Address - Phone:870-523-6728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN7174207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5B232OtherBLUECROSSBLUESHIELD
52346Medicare ID - Type Unspecified
B90299Medicare UPIN