MEDICARE: DR. GORDON I HERZ PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	1715	WI
2	103TC0700X	Clinical Psychologist	1715	WI

General Provider Information

NPI Number	:	1053314344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON I HERZ PHD

Provider Business Mailing Address
First Line	:	478 COMMERCE DR
Second Line	:	STE 204
City	:	MADISON
State	:	WI
Zip	:	53719-4993
Country	:	US
Telephone Number	:	608-833-7533
Fax Number	:

Provider Business Practice Location Address
First Line	:	478 COMMERCE DR
Second Line	:	STE 204
City	:	MADISON
State	:	WI
Zip	:	53719-4993
Country	:	US
Telephone Number	:	608-833-7533
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	04/23/2014

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