Basic Information
Provider Information | |||||||||
NPI: | 1770897522 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERRICO | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | ANTHONY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14417 | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314161417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9126292290 | ||||||||
FaxNumber: | 9126292291 | ||||||||
Practice Location | |||||||||
Address1: | 11700 MERCY BLVD | ||||||||
Address2: | PLAZA D, BLDG. 5 | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314191753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9129276270 | ||||||||
FaxNumber: | 9129276254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2010 | ||||||||
LastUpdateDate: | 08/12/2015 | ||||||||
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 | 2084N0400X | 36180 | SC | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 74181 | GA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207RC0200X | 74181 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 174400000X | 74181 | GA | N |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 003162574A | 05 | GA |   | MEDICAID |