Provider Demographics
NPI:1750543674
Name:HERZOG, MARY A (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:HERZOG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LAFAYETTE AVE SE # 3400
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE AVE SE # 3400
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4600
Practice Address - Country:US
Practice Address - Phone:616-752-6615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093037207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery