Basic Information
Provider Information | |||||||||
NPI: | 1760465603 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERMAN | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1120 DELSEA DR N | ||||||||
Address2: |   | ||||||||
City: | GLASSBORO | ||||||||
State: | NJ | ||||||||
PostalCode: | 080281444 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8568532055 | ||||||||
FaxNumber: | 8566865218 | ||||||||
Practice Location | |||||||||
Address1: | 75 W RED BANK AVE | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | NJ | ||||||||
PostalCode: | 080961694 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8568532055 | ||||||||
FaxNumber: | 8566865218 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2005 | ||||||||
LastUpdateDate: | 06/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MA67166 | NJ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7872208 | 05 | NJ |   | MEDICAID |