Provider Demographics
NPI:1144338930
Name:FRIESS, ERIC G (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:G
Last Name:FRIESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4242 LORAIN AVE
Mailing Address - Street 2:THOMAS F. MCCAFFERTY HEALTH CENTER
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3715
Mailing Address - Country:US
Mailing Address - Phone:216-651-3740
Mailing Address - Fax:
Practice Address - Street 1:4242 LORAIN AVE
Practice Address - Street 2:THOMAS F. MCCAFFERTY HEALTH CENTER
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3715
Practice Address - Country:US
Practice Address - Phone:216-651-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0313039Medicaid
OHFR7271451Medicare ID - Type Unspecified
OH0313039Medicaid