Basic Information
| Provider Information | |||||||||
| NPI: | 1447419536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL ASSOCIATES OF ERIE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPORTS MEDICINE AND INTEGRATIVE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LECOM PL | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165052571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145289709 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5515 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165092603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148644031 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 06/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | STYN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8145289709 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083S0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 101066458 | 05 | PA | MEDICAID |