Basic Information
| Provider Information | |||||||||
| NPI: | 1104944677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL ASSOCIATES OF ERIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1858 W GRANDVIEW BLVD | ||||||||
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| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165091025 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2010 W 38TH ST | ||||||||
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| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148685481 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STYN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8148668468 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207X00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1010664580008 | 05 | PA | MEDICAID |