=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699900217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN HERSPERGER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2009
-----------------------------------------------------
Last Update Date | 11/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 W UNDERWOOD ST STE 200
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-649-6884
-----------------------------------------------------
Fax | 407-245-7059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 W UNDERWOOD ST STE 200
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-649-6884
-----------------------------------------------------
Fax | 407-245-7059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0102X
-----------------------------------------------------
Taxonomy Name | Surgical Critical Care Physician
-----------------------------------------------------
License Number | ME128880
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------