Basic Information
| Provider Information | |||||||||
| NPI: | 1003025016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVRIES | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | 5-NORTH PEDIATRICS | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914000 | ||||||||
| FaxNumber: | 4194796102 | ||||||||
| Practice Location | |||||||||
| Address1: | 2142 N COVE BLVD | ||||||||
| Address2: | 5-NORTH PEDIATRICS | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192914000 | ||||||||
| FaxNumber: | 4194796102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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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 | 208000000X | 37245 | IA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 35088762 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1003025016 | 05 | IA | MEDICAID |