Provider Demographics
NPI:1699084939
Name:HERDEMAN, EVAN R (DPT)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:HERDEMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 GLEN ESTE WITHAMSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-1318
Mailing Address - Country:US
Mailing Address - Phone:513-943-3630
Mailing Address - Fax:513-753-4308
Practice Address - Street 1:4440 GLEN ESTE WITHAMSVILLE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1318
Practice Address - Country:US
Practice Address - Phone:513-943-3630
Practice Address - Fax:513-753-4308
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013062225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3123551Medicaid
OH000000685484OtherANTHEM
OH0225920002Medicare NSC
OHH247610Medicare PIN