MEDICARE: STEVEN HERZOG D.D.S., M.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	019-016111	IL
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	019-016111	IL

Other Identifiers

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

General Provider Information

NPI Number	:	1306063631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN HERZOG D.D.S., M.S.

Provider Business Mailing Address
First Line	:	2440 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4113
Country	:	US
Telephone Number	:	773-761-7171
Fax Number	:	773-761-6714

Provider Business Practice Location Address
First Line	:	2440 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4113
Country	:	US
Telephone Number	:	773-761-7171
Fax Number	:	773-761-6714

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	12/16/2019

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