1629085519 NPI number — ALEX M HERZBERG MD

Table of content: ALEX M HERZBERG MD (NPI 1629085519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629085519 NPI number — ALEX M HERZBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERZBERG
Provider First Name:
ALEX
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1629085519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 22487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54305-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-445-7226
Provider Business Mailing Address Fax Number:
920-445-7238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 NE 139TH ST
Provider Second Line Business Practice Location Address:
#140
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-2719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-882-2778
Provider Business Practice Location Address Fax Number:
360-604-1697
Provider Enumeration Date:
08/02/2006

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: 207X00000X , with the licence number:  MD21166 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 66572-20 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: MD60431541 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 001920 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 276799 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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