Basic Information
| Provider Information | |||||||||
| NPI: | 1073503181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERTZOG | ||||||||
| FirstName: | ROXANNE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5908 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980060408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062441212 | ||||||||
| FaxNumber: | 2062441223 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 PACIFIC AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062441212 | ||||||||
| FaxNumber: | 2062441223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00032736 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8938073 | 01 | WA | CRIME VICTIMS PROGRAM | OTHER | 4682HE | 01 | WA | REGENCE BLUE SHIELD | OTHER | 0184996 | 01 | WA | DEPT OF LABOR & INDUSTRIE | OTHER | 8017535 | 05 | WA | MEDICAID |