Basic Information
| Provider Information | |||||||||
| NPI: | 1134147325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERTWECK | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERTWECK | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | PAIGE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 766351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 3991 DUTCHMANS LN STE 303 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025591750 | ||||||||
| FaxNumber: | 5026667707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 25239 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 207VG0400X | 25239 | KY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 100332440 | 05 | IN | MEDICAID | 1049243 | 01 | KY | PASSPORT SPECIALITY - FOUNDATION | OTHER | 000000047600 | 01 | KY | ANTHEM - FOUNDATION | OTHER | 64252398 | 05 | KY | MEDICAID | 1049273 | 01 | KY | PASSPORT SPECIALITY - PSC | OTHER | K027510 | 01 | KY | MEDICARE PTAN | OTHER | 1049241 | 01 | KY | PASSPORT PCP# - FOUNDATION | OTHER | 50034184 | 01 | KY | PASSPORT & PASSPORT ADVTG | OTHER | 000000045416 | 01 | KY | ANTHEM - PSC | OTHER |