Basic Information
| Provider Information | |||||||||
| NPI: | 1265688352 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERICKSON HEALTH MEDICAL GROUP OF MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5525 RESEARCH PARK DR | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212284664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104022258 | ||||||||
| FaxNumber: | 4102047279 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BROOKSBY VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019601438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367850 | ||||||||
| FaxNumber: | 8772809727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2008 | ||||||||
| LastUpdateDate: | 09/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | NARRETT | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP/CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4104022261 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 6269910001 | 01 | DME | OTHER |