Basic Information
| Provider Information | |||||||||
| NPI: | 1336188945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERTZOG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416210 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022411407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106448900 | ||||||||
| FaxNumber: | 4849240053 | ||||||||
| Practice Location | |||||||||
| Address1: | 2412 W PASSYUNK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191454114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154622100 | ||||||||
| FaxNumber: | 2154623100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD027999E | PA | N | Allopathic & Osteopathic Physicians | Surgery | 2085R0204X | MD027999E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1336188945 | 05 | MO | MEDICAID | 0045155000 | 01 | NJ | AMERIHEALTH | OTHER | 0506464005 | 01 | NJ | CIGNA | OTHER | 3435709 | 05 | NJ | MEDICAID | 36952 | 01 | NJ | AETNA | OTHER | MES131 | 01 | NJ | OXFORD | OTHER |