Healthcare Provider Details

I. General information

NPI: 1386724649
Provider Name (Legal Business Name): ALBERT HERGENROEDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 FANNIN ST
HOUSTON TX
77030-2316
US

IV. Provider business mailing address

6701 FANNIN ST
HOUSTON TX
77030-2316
US

V. Phone/Fax

Practice location:
  • Phone: 832-822-2778
  • Fax: 832-825-3141
Mailing address:
  • Phone: 832-822-2778
  • Fax: 832-825-3141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberH1493
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: