Basic Information
| Provider Information | |||||||||
| NPI: | 1467989582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAVALORO | ||||||||
| FirstName: | ERCOLE | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840134 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701840134 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1202 S TYLER ST | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704332330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858984000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2017 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R76317 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 207P00000X | R76317 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.