Provider Demographics
NPI:1861525263
Name:ERIE MEDICAL SPECIALTY CLINIC, PC
Entity type:Organization
Organization Name:ERIE MEDICAL SPECIALTY CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, CLINICAL ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARYBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-877-5564
Mailing Address - Street 1:104 E 2ND ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1532
Mailing Address - Country:US
Mailing Address - Phone:814-877-5564
Mailing Address - Fax:814-877-5561
Practice Address - Street 1:104 E 2ND ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1532
Practice Address - Country:US
Practice Address - Phone:814-877-5564
Practice Address - Fax:814-877-5561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025800E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherPRACTICE TAX ID