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General NPI Number Information
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NPI Number | 1750543674
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Entity Type | Individual
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Provider Name | MARY A HERZOG MD
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Gender | Female
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Dates
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Enumeration Date | 07/01/2008
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Last Update Date | 07/01/2008
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Provider Practice Location Address
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Address Line | 300 LAFAYETTE AVE SE # 3400
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-4600
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Country | US
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Telephone | 616-752-6615
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Fax |
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Provider Business Mailing Address
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Address Line | 300 LAFAYETTE AVE SE # 3400
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-4600
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 4301093037
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License Number State | MI
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