Provider Demographics
NPI:1033239199
Name:MARDERSTEIN, ERIC L (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:MARDERSTEIN
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 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:440-684-5865
Practice Address - Fax:440-684-5952
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-088879208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2730398Medicaid
OH000000221050OtherUNISON
9779061OtherAETNA
000000524529OtherANTHEM
OH414685OtherWELLCARE
OHP00397851OtherRAILROAD MEDICARE
OH750895OtherBUCKEYE
000000524529OtherANTHEM