Basic Information
| Provider Information | |||||||||
| NPI: | 1457344921 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEVINE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 104 E 2ND ST | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148776111 | ||||||||
| FaxNumber: | 8148776356 | ||||||||
| Practice Location | |||||||||
| Address1: | 9141 GRANT ST STE 125 | ||||||||
| Address2: | |||||||||
| City: | THORNTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802294367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034532460 | ||||||||
| FaxNumber: | 3034532460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD067802L | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00025821201 | 01 | NY | UNIVERA | OTHER | 1508396 | 01 | PA | GATEWAY | OTHER | 0017599780004 | 05 | PA | MEDICAID | 1068850 | 01 | WV | WEST VIRGINIA WORK COMP | OTHER | 119508 | 01 | PA | UNISON | OTHER | 2988615 | 01 | PA | AETNA | OTHER | 217386 | 01 | PA | UPMC | OTHER | 02166407 | 01 | NY | NY MEDICAL ASSISTANCE | OTHER | 612674 | 01 | PA | BLUESHIELD | OTHER | 020049122 | 01 | PA | RR MEDICARE | OTHER | 2248875 | 01 | OH | OH MEDICAL ASSISTANCE | OTHER |