Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 019-016111 | IL |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 019-016111 | IL |
NPI | 1306063631 |
---|---|
Provider Name | Steven Herzog |
First Address | Chicago, IL 60659-4113 |
Second Address | Chicago, IL 60659-4113 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2007 |
Last Update Date | 16/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
019016111 | (05) | IL |
T74901 | (02) | IL |