Basic Information
| Provider Information | |||||||||
| NPI: | 1770778672 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ERIE SHORE WOMENS HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 524 CLEVELAND ST | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440354055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409348344 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5054 WATERFORD PLACE DR | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409348344 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 12/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | KOVACH | ||||||||
| AuthorizedOfficialFirstName: | CORIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4409348344 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2637721 | 05 | OH | MEDICAID | DF0746 | 01 | OH | PALMETTO GBA RETIRED | OTHER | 000000387553 | 01 | OH | ANTHEM BLUE CROSS | OTHER |