Basic Information
| Provider Information | |||||||||
| NPI: | 1720312903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERGO OCCMED, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6196 OXON HILL RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | OXON HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207453100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015676400 | ||||||||
| FaxNumber: | 2023188174 | ||||||||
| Practice Location | |||||||||
| Address1: | 6196 OXON HILL RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | OXON HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207453100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015676400 | ||||||||
| FaxNumber: | 2023188174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | EZEANI | ||||||||
| AuthorizedOfficialFirstName: | OLU | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/ OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3015297479 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | PT870468 | DC | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 19226 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 052848800 | 05 | DC | MEDICAID | 420375500 | 05 | MD | MEDICAID |