MEDICARE: MR. JAMES HERZOG C.S.A.

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	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1437190824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES HERZOG C.S.A.

Provider Business Mailing Address
First Line	:	1104 W GLENHAVEN DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85045-0733
Country	:	US
Telephone Number	:	480-706-9430
Fax Number	:	480-461-0945

Provider Business Practice Location Address
First Line	:	1104 W GLENHAVEN DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85045-0733
Country	:	US
Telephone Number	:	480-706-9430
Fax Number	:	480-461-0945

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	07/08/2007

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