MEDICARE: JOHN L HERZOG SR. MD

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	207RC0000X	Cardiovascular Disease Physician	09800	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	060000624	OTHER	MS	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093734949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN L HERZOG SR. MD

Provider Business Mailing Address
First Line	:	PO BOX 5368
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38704-5368
Country	:	US
Telephone Number	:	662-394-0107
Fax Number	:	662-335-7184

Provider Business Practice Location Address
First Line	:	1421 E UNION ST
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38703-3247
Country	:	US
Telephone Number	:	662-335-0183
Fax Number	:	662-335-7184

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	08/21/2020

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Directions to “ JOHN L HERZOG SR. MD” Practice Location

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