Basic Information
Provider Information | |||||||||
NPI: | 1801059894 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERCOLANI | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: | CORBYONS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 25487 | ||||||||
Address2: |   | ||||||||
City: | SARASOTA | ||||||||
State: | FL | ||||||||
PostalCode: | 342772487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9412025342 | ||||||||
FaxNumber: | 8552534836 | ||||||||
Practice Location | |||||||||
Address1: | 401 COMMERCIAL CT STE E | ||||||||
Address2: |   | ||||||||
City: | VENICE | ||||||||
State: | FL | ||||||||
PostalCode: | 342921652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9412604440 | ||||||||
FaxNumber: | 9412604441 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2008 | ||||||||
LastUpdateDate: | 05/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 25MA08338400 | NJ | N |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | ME107060 | FL | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 344433 | 01 | FL | AVMED | OTHER | 14A1Y | 01 | FL | BCBS FL | OTHER | P986609 | 01 | FL | FREEDOM HEALTH | OTHER | 8962967 | 01 | FL | CIGNA | OTHER | 1193012 | 01 | FL | WELLCARE | OTHER | P931608 | 01 | FL | OPTIMUM | OTHER | EP988X | 01 | FL | MEDICARE (ARCADIA OFFICE) | OTHER | P00924559 | 01 | FL | RAILROAD MEDICARE | OTHER | 9592610 | 01 | FL | AETNA | OTHER |