Provider Demographics
NPI:1649367731
Name:HERROLD, EDMUND M (MD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:M
Last Name:HERROLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 MADISON AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022
Mailing Address - Country:US
Mailing Address - Phone:212-249-2820
Mailing Address - Fax:212-249-6856
Practice Address - Street 1:635 MADISON AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:212-746-2108
Practice Address - Fax:212-746-8448
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149191207R00000X, 207RC0000X
NY149191-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00893196Medicaid
NY23D011Medicare ID - Type Unspecified
NY00893196Medicaid