Provider Demographics
NPI:1497739080
Name:HERTZBERG, MARK G (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:HERTZBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44150 12 MILE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377
Mailing Address - Country:US
Mailing Address - Phone:248-347-5800
Mailing Address - Fax:
Practice Address - Street 1:44150 12 MILE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-347-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI06314532OtherBCBS INDIVIDUAL
MI1106314532OtherBLUE CROSS
MIB43383Medicare UPIN
MI0M55750Medicare PIN
MI0P61570Medicare PIN