MEDICARE: ROBERT ROWEN HERZOG PT

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	2251P0200X	Pediatric Physical Therapist	35698	CA

General Provider Information

NPI Number	:	1053382911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT ROWEN HERZOG PT

Provider Business Mailing Address
First Line	:	8690 PETALUMA HILL RD
Second Line	:
City	:	PENNGROVE
State	:	CA
Zip	:	94951-8734
Country	:	US
Telephone Number	:	707-779-9162
Fax Number	:

Provider Business Practice Location Address
First Line	:	8690 PETALUMA HILL RD
Second Line	:
City	:	PENNGROVE
State	:	CA
Zip	:	94951-8734
Country	:	US
Telephone Number	:	707-779-9162
Fax Number	:

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	01/08/2014

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