Basic Information
| Provider Information | |||||||||
| NPI: | 1285634113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | HERNANDO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 BERWYN HOUSE RD STE 208 | ||||||||
| Address2: | COLLEGE PARK | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207404719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012200150 | ||||||||
| FaxNumber: | 3012201032 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 HOSPITAL DRIVE | ||||||||
| Address2: | CITY HOSPITAL | ||||||||
| City: | MARTINSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042641212 | ||||||||
| FaxNumber: | 3042640135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZN0500X | 10129 | WV | Y | Allopathic & Osteopathic Physicians | Pathology | Neuropathology | 207ZP0101X | 10129 | WV | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0105X | 0101022951 | VA | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 220021414 | 01 | WV | RAILROAD MEDICARE | OTHER | 0101738000 | 05 | WV | MEDICAID |