Hazen Timothy Herzog, PHYSICIAN ASSISTANT

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

License

PA152638 Issued in OR

Practice address

1900 Woodland Dr
Coos Bay, OR 97420-2045

Phone

(541) 267-5151

Fax

(541) 266-4501

NPI assigned

Sep 21, 2009

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 8

Medicare fee-for-service enrollment

Enrolled in ID

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2009

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

St Lukes Clinic-Treasure Valley LLCGroup PAC ID 4981878402, 1,155 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• St Luke'S Regional Medical Center Hospital, Boise, ID, CCN 130006
• St Luke'S Nampa Medical Center Hospital, Nampa, ID, CCN 130071

Merit-based Incentive Payment System (MIPS)

Final score

87.3 of 100Reported as group

Quality

81.29

Promoting interoperability

100

Improvement activities

40

Cost

76.37

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: hherzog84097@direct.slhs.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• St Lukes Clinic-Treasure Valley LLC

  • Family Medicine Physician
  • Boise, ID
  • NPI 1326336058
  Medicare reassignment Care Compare group NPD
• St Lukes Regional Medical Center

  • General Acute Care Hospital
  • Boise, ID
  • NPI 1770586794
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• St Lukes Regional Medical Center

  • Ambulance
  • Boise, ID
  • NPI 1518115195

  Hospital

  Care Compare affiliation
• St Lukes Regional Medical Center

  • General Acute Care Hospital
  • Boise, ID
  • NPI 1770586794
  Care Compare affiliation
• St Lukes West LTD

  • General Acute Care Hospital
  • Nampa, ID
  • NPI 1831590660
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1253491200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1383868800000",
    "number": "1932433190",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1900 WOODLAND DR",
            "city": "COOS BAY",
            "state": "OR",
            "postal_code": "974202045",
            "telephone_number": "541-267-5151",
            "fax_number": "541-266-4501"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1900 WOODLAND DR",
            "city": "COOS BAY",
            "state": "OR",
            "postal_code": "974202045",
            "telephone_number": "541-267-5151",
            "fax_number": "541-266-4501"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HERZOG",
        "first_name": "HAZEN",
        "middle_name": "TIMOTHY",
        "credential": "PHYSICIAN ASSISTANT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-09-21",
        "last_updated": "2013-11-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "UT",
            "license": "7462373-1206",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "OR",
            "license": "PA152638",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICAID NORTH BEND MEDICAL CENTER",
            "identifier": "161133",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500625533",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "74623731206",
            "state": "UT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P01220506",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP MEDICARE NORTH BEND MEDICAL CENTER",
            "identifier": "R000WFBTV",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP NPI NORTH BEND MEDICAL CENTER",
            "identifier": "1407812365",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP TAX FOR BILLING NORTH BEND MEDICAL CENTER",
            "identifier": "93-0635514",
            "state": "OR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE",
            "identifier": "PA152638",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Allison Henrie, MS RD LD CDCES
• Kevin Dale Hensley
• Jessica Ann Alexandria Hernandez
• Mary Irene Hernandez, MPT, CWS
• Benjamin Herron, DC
• Kelly Marie Herzog
• Sarah Linn Hicks, LMT
• Don W. Hill, M.D., F.A.C.P.
• Gina Hill
• Ranae Hill

• Surgical Physician Assistant in Coos Bay, OR
• Providers in Coos Bay, OR by specialty
• Surgical Physician Assistant in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.