Provider Demographics
NPI:1528178340
Name:HERBERT, GARY CLYDE (DC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:CLYDE
Last Name:HERBERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15132
Mailing Address - Country:US
Mailing Address - Phone:412-673-3320
Mailing Address - Fax:412-673-6520
Practice Address - Street 1:3020 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15132
Practice Address - Country:US
Practice Address - Phone:412-673-3320
Practice Address - Fax:412-673-6520
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002307L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T30006Medicare UPIN
PA0736070Medicare ID - Type Unspecified
HE185319Medicare ID - Type Unspecified