Basic Information
Provider Information | |||||||||
NPI: | 1710972047 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STALLKAMP | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | TODD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 636930 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452630001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5139815123 | ||||||||
FaxNumber: | 5139815015 | ||||||||
Practice Location | |||||||||
Address1: | 582 N CABLE RD | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458052133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199962500 | ||||||||
FaxNumber: | 4199962509 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2005 | ||||||||
LastUpdateDate: | 09/10/2013 | ||||||||
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 | 207Q00000X | 350731165 | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080142578 | 01 | OH | TRAVELERS/RAILROAD MEDICA | OTHER | 1134112469 | 01 |   | GROUP NPI# PRIMARY OFFICE | OTHER | 2062075 | 05 | OH |   | MEDICAID | 000000136496 | 01 | OH | ANTHEM BC/BS PROVIDER # | OTHER | 1669550182 | 01 |   | GROUP NPI# SATELLITE OFFI | OTHER |