Basic Information
| Provider Information | |||||||||
| NPI: | 1093707499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERCHOLD | ||||||||
| FirstName: | JACEK | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HERCHOLD | ||||||||
| OtherFirstName: | JACK | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15650 N BLACK CANYON HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850534064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028660550 | ||||||||
| FaxNumber: | 6029935788 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 W WHISPERING WIND DR | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850852853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028660550 | ||||||||
| FaxNumber: | 6029935788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 17909 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 282012 | 05 | AZ | MEDICAID |