Basic Information
| Provider Information | |||||||||
| NPI: | 1588653190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 173 HOLLYWOOD ST | ||||||||
| Address2: | |||||||||
| City: | OBERLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440741009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407746929 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 W LORAIN ST | ||||||||
| Address2: | |||||||||
| City: | OBERLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440741026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4407751211 | ||||||||
| FaxNumber: | 4407745707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35078673 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2547793 | 05 | OH | MEDICAID | 000000518261 | 01 | OH | BCBS | OTHER | P00406924 | 01 | RAILROAD | OTHER |