1619909850 NPI number — THOMAS HERZOG M.D.

Table of content: THOMAS HERZOG M.D. (NPI 1619909850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619909850 NPI number — THOMAS HERZOG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERZOG
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1619909850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
237 WILLIAM HOWARD TAFT, PHYS DIV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45219-2906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-585-2323
Provider Business Mailing Address Fax Number:
513-585-4893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2139 AUBURN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45219-2906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-585-2323
Provider Business Practice Location Address Fax Number:
513-585-4893
Provider Enumeration Date:
07/07/2006

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: 207VX0201X , with the licence number:  231790-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0201X , with the licence number: 35 057399 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0107031 . This is a "MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 7100315370 . This is a "MEDICAID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 02561113 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201249540 . This is a "MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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