Provider Demographics
NPI:1568635720
Name:CHRISTOPHER F HERZOG, D.O., PC
Entity Type:Organization
Organization Name:CHRISTOPHER F HERZOG, D.O., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-603-2020
Mailing Address - Street 1:9463 HOLLY RD
Mailing Address - Street 2:STE 101
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2557
Mailing Address - Country:US
Mailing Address - Phone:810-603-2020
Mailing Address - Fax:810-603-2042
Practice Address - Street 1:9463 HOLLY RD
Practice Address - Street 2:STE 101
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2557
Practice Address - Country:US
Practice Address - Phone:810-603-2020
Practice Address - Fax:810-603-2042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009262207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2969290Medicaid
MI2969290Medicaid
MI0714060001Medicare NSC
MI5250906Medicare PIN