=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386685725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRY A HERDT MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 W HOMER ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47167-1698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-883-8772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10330 N MERIDIAN ST # 300
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46290-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 01031253
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------