Basic Information
| Provider Information | |||||||||
| NPI: | 1609216654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEISACH | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | R.D., L.D.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816460 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | STE 605 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102665667 | ||||||||
| FaxNumber: | 4102669332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2013 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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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 | DX3240 | MD | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | Y9100003 | 01 | MD | BCBS | OTHER |