Basic Information
| Provider Information | |||||||||
| NPI: | 1164432639 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERICKSON HEALTH MEDICAL GROUP OF TEXAS PA | ||||||||
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| OtherOrganizationName: | HIGHLAND SPRINGS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5525 RESEARCH PARK DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722328080 | ||||||||
| FaxNumber: | 9722328099 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 FRANKFORD RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752526834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722328080 | ||||||||
| FaxNumber: | 9722328099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | NORMAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4104022257 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 364SP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 364SG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0089EP | 01 | BCBS - FEATHERSTON | OTHER | 01-29391 | 01 | EVERCARE | OTHER | 8AS969 | 01 | BCBS - FEATHERSTON | OTHER | 8BW701 | 01 | BCBS OF TX | OTHER | 04-60996 | 01 | EVERCARE | OTHER | 260341853001 | 01 | TRICARE | OTHER | 0093NP | 01 | BCBS OF TX | OTHER |