Basic Information
| Provider Information | |||||||||
| NPI: | 1891029880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERINGHAUS | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5620 SILVER FALLS ST | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430167847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192361868 | ||||||||
| FaxNumber: | 6145833300 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S CLEVELAND AVE | ||||||||
| Address2: | ANESTHESIA DEPT/COA | ||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430818971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148986659 | ||||||||
| FaxNumber: | 6148988631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2009 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
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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 | 367H00000X | 67.000192 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0078670 | 05 | OH | MEDICAID | XXXXX8807-00 | 01 | OH | OHIO BWC | OTHER | 000000806012 | 01 | OH | ANTHEM OHIO | OTHER |