Provider Demographics
NPI:1831231083
Name:DENNIS A. HERZOG, M.D.,P.C
Entity type:Organization
Organization Name:DENNIS A. HERZOG, M.D.,P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-225-3970
Mailing Address - Street 1:1414 W FAIR AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5409
Mailing Address - Country:US
Mailing Address - Phone:906-225-3970
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE STE 240
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5409
Practice Address - Country:US
Practice Address - Phone:906-225-3970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035261207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101658376Medicaid
MI0705200122OtherBLUE CROSS BLUE SHIELD MI
MI101658376Medicaid
MI0P52870Medicare PIN
MI0520012Medicare PIN
MIB44245Medicare UPIN