Basic Information
| Provider Information | |||||||||
| NPI: | 1205298189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERMELIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1959 NE PACIFIC ST RM BB-527 | ||||||||
| Address2: | BOX 356421 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981956421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065433605 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21212 NORTHWEST FWY STE 505 | ||||||||
| Address2: | |||||||||
| City: | CYPRESS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774295888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326888400 | ||||||||
| FaxNumber: | 8326888430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2016 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | S1607 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | S1607 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.