Basic Information
| Provider Information | |||||||||
| NPI: | 1790785319 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EGGLESTON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 STATE ST | ||||||||
| Address2: | SUITE 16, LL | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165011341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144807100 | ||||||||
| FaxNumber: | 8144807604 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 STATE ST | ||||||||
| Address2: | HAMOT EMERGENCY ROOM | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165500002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148776139 | ||||||||
| FaxNumber: | 8148776093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS011861 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02593433 | 01 | NY | NY MEDICAL ASSISTANCE | OTHER | 1011365700001 | 05 | PA | MEDICAID | 2484753 | 01 | OH | OH MEDICAL ASSISTANCE | OTHER | 410043 | 01 | PA | UPMC | OTHER | 00026790801 | 01 | NY | UNIVERA | OTHER | 7895534 | 01 | PA | AETNA | OTHER | 1068837 | 01 | WV | W. VIRGINIA WORKERS COMP | OTHER | 1537945 | 01 | PA | GATEWAY | OTHER | 1625163 | 01 | PA | BLUE SHIELD | OTHER | P00147174 | 01 | PA | RR MEDICARE | OTHER | 156601 | 01 | PA | UNISON | OTHER |