1073503181 NPI number — DR. ROXANNE E HERTZOG M.D.

Table of content: DR. ROXANNE E HERTZOG M.D. (NPI 1073503181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073503181 NPI number — DR. ROXANNE E HERTZOG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERTZOG
Provider First Name:
ROXANNE
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073503181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5908
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98006-0408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-244-1212
Provider Business Mailing Address Fax Number:
206-244-1223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 PACIFIC AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-4261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-244-1212
Provider Business Practice Location Address Fax Number:
206-244-1223
Provider Enumeration Date:
10/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  MD00032736 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8938073 . This is a "CRIME VICTIMS PROGRAM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4682HE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0184996 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8017535 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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