Basic Information
| Provider Information | |||||||||
| NPI: | 1982651360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICH | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOFFA | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1718 PATTERSON ST | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372032926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153468546 | ||||||||
| FaxNumber: | 6153468547 | ||||||||
| Practice Location | |||||||||
| Address1: | 1718 PATTERSON ST | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372032926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153468546 | ||||||||
| FaxNumber: | 6153468547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD070279L | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | D47172 | MD | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PH0002X | 65277 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1613627 | 01 | PA | GATEWAY | OTHER | 2742186 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 102760401 | 05 | PA | MEDICAID | 418989 | 01 | PA | UPMC | OTHER | 145691100 | 05 | MD | MEDICAID | 30139168 | 01 | PA | AMERIHEALTH MERCY-YH | OTHER | Q074709 | 05 | TN | MEDICAID |