Basic Information
| Provider Information | |||||||||
| NPI: | 1326414251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERDELYI | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRILLIOT | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | MAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD, LD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6421 S RANGELINE RD | ||||||||
| Address2: | |||||||||
| City: | WEST MILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453839605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375813198 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455042687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375231000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2015 | ||||||||
| LastUpdateDate: | 08/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 7655 | OH | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.