Provider Demographics
NPI:1902887508
Name:THOMAS ERIC HERZOG INC
Entity Type:Organization
Organization Name:THOMAS ERIC HERZOG INC
Other - Org Name:INDIANHEAD EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-635-3127
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-0446
Mailing Address - Country:US
Mailing Address - Phone:715-635-3127
Mailing Address - Fax:715-635-3316
Practice Address - Street 1:W7164 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-6605
Practice Address - Country:US
Practice Address - Phone:715-635-3127
Practice Address - Fax:715-635-3316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIDG1708OtherPALMETTO RR MEDICARE
WI38711400Medicaid
000087430Medicare PIN
WIDG1708OtherPALMETTO RR MEDICARE