Provider Demographics
NPI:1033644406
Name:ERUM, NO NAME GIVEN (MD)
Entity Type:Individual
Prefix:
First Name:NO NAME GIVEN
Middle Name:
Last Name:ERUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FNU
Other - Middle Name:
Other - Last Name:ERUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 WOODLAND WAY
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9802
Mailing Address - Country:US
Mailing Address - Phone:908-906-1220
Mailing Address - Fax:
Practice Address - Street 1:101 DATES DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1342
Practice Address - Country:US
Practice Address - Phone:607-274-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY3081062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program