Provider Demographics
NPI:1801042114
Name:MARK HERTZBERG MD PC
Entity Type:Organization
Organization Name:MARK HERTZBERG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:HERTZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD PC
Authorized Official - Phone:248-347-5800
Mailing Address - Street 1:44150 12 MILE
Mailing Address - Street 2:STE 100
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377
Mailing Address - Country:US
Mailing Address - Phone:248-357-3225
Mailing Address - Fax:
Practice Address - Street 1:44150 TWELVE MILE ROAD
Practice Address - Street 2:STE 100
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-357-3225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1106314532OtherBLUE CROSS
MI0P61570Medicare PIN