Basic Information
| Provider Information | |||||||||
| NPI: | 1316995574 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LANCASTER AVE | ||||||||
| Address2: | 353 MEDICAL OFFICE BUILDING EAST | ||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190963450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106499021 | ||||||||
| FaxNumber: | 6106498058 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E LANCASTER AVE | ||||||||
| Address2: | 353 MEDICAL OFFICE BUILDING EAST | ||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190963450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106499021 | ||||||||
| FaxNumber: | 6106498058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | OS011047L | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 25MB06319700 | NJ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0184927006 | 01 | PA | AMERICHOICE | OTHER | 02640 | 01 | PA | HEALTH PARTNERS | OTHER | 1652891 | 01 | PA | BC/BS HIGHMARK GROUP | OTHER | 2330386000 | 01 | PA | BC/BS KEY, PER. GROUP | OTHER | 33658 | 01 | PA | HEALTH PARTNERS | OTHER | 3716959 | 01 | PA | AETNA US HEALTHCARE GROUP | OTHER | 00184927 | 05 | PA | MEDICAID | 00866773000 | 01 | PA | BC/BS KEYSTONE, PERSONAL | OTHER | 33657 | 01 | PA | HEALTH PARTNERS | OTHER | 33659 | 01 | PA | HEALTH PARTNERS | OTHER | 3716982 | 01 | PA | AETNA US HEALTHCARE HMO | OTHER | 30018993 | 01 | PA | KEYSTONE MERCY | OTHER | 923742 | 01 | PA | BC/BS SHIELD HIGHMARK | OTHER | 30018989 | 01 | PA | KEYSTONE MERCY GROUP | OTHER | 5824670 | 01 | PA | AETNA US HEALTHCARE | OTHER |