Provider Demographics
NPI:1821156175
Name:PETER HERTZAK, M.D., PMC
Entity Type:Organization
Organization Name:PETER HERTZAK, M.D., PMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-690-8349
Mailing Address - Street 1:985 ROBERT BLVD.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458
Mailing Address - Country:US
Mailing Address - Phone:985-641-6300
Mailing Address - Fax:985-646-1409
Practice Address - Street 1:985 ROBERT BLVD.
Practice Address - Street 2:SUITE 105
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458
Practice Address - Country:US
Practice Address - Phone:985-641-6300
Practice Address - Fax:985-646-1409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05273R207V00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1311308Medicaid
LA52940Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
LA1311308Medicaid