=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003255019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY JAY HERZOG MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2013
-----------------------------------------------------
Last Update Date | 05/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 MALABAR RD NE
-----------------------------------------------------
City | PALM BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32907-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-434-8078
-----------------------------------------------------
Fax | 321-434-8075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 S FISKE BLVD
-----------------------------------------------------
City | ROCKLEDGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32955-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-434-8078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | ME130900
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------