Basic Information
| Provider Information | |||||||||
| NPI: | 1235149477 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERICKSON HEALTH MEDICAL GROUP OF PENNSYLVANIA PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARIS GROVE 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: | 6103874520 | ||||||||
| FaxNumber: | 6103874526 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MARIS GROVE WAY | ||||||||
| Address2: | |||||||||
| City: | GLEN MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103874520 | ||||||||
| FaxNumber: | 6103874526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NARRETT | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP AND CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4104022257 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family 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 | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2045582 | 01 | HIGHMARK BS | OTHER | 01-24638 | 01 | EVERCARE | OTHER | 2055836 | 01 | HIGHMARK BLUE SHIELD PODIATRISTS | OTHER | 22-55915002 | 01 | KEYSTONE | OTHER | 2055830 | 01 | HIGHMARK BLUE SHIELD | OTHER | 758848 | 01 | BCBS OF PA | OTHER |