MEDICARE: DR. RICHARD J HEROLD 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	207R00000X	Internal Medicine Physician	1637071205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11017608	OTHER	UT	UNION PACIFIC RAILROAD
2	15032	OTHER	UT	IHC

General Provider Information

NPI Number	:	1891799318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD J HEROLD MD

Provider Business Mailing Address
First Line	:	PO BOX 742382
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-2382
Country	:	US
Telephone Number	:
Fax Number	:	801-270-3395

Provider Business Practice Location Address
First Line	:	1160 E 3900 S STE G200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124
Country	:	US
Telephone Number	:	801-268-7766
Fax Number	:	801-270-3395

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	11/25/2020

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