Provider Demographics
NPI:1972572113
Name:HIRSCH, LARRY KEITH (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:KEITH
Last Name:HIRSCH
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 1:9201 DRAKE AVE
Mailing Address - Street 2:APT. 102
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1650
Mailing Address - Country:US
Mailing Address - Phone:847-673-5645
Mailing Address - Fax:
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:CONEMAUGH EMERGENCY PHYSICIANS GROUP
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905
Practice Address - Country:US
Practice Address - Phone:814-534-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019885E207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1972572113Medicaid
KY64129109Medicaid
PA007365139Medicaid
VA1972572113Medicaid
KY64129109Medicaid
WV0850817Medicare PIN
KYK098723Medicare PIN