Basic Information
| Provider Information | |||||||||
| NPI: | 1629067137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERMAN | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 79671 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212790671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573883221 | ||||||||
| FaxNumber: | 7573883799 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 GODWIN BLVD | ||||||||
| Address2: | PATHOLOGY DEPT | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234348038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579344000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 06/29/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 0101054078 | VA | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 0101054078 | VA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1629067137 | 05 | VA | MEDICAID |