Provider Demographics
NPI:1114901485
Name:ERMOLIN, VITALY E (MD)
Entity Type:Individual
Prefix:
First Name:VITALY
Middle Name:E
Last Name:ERMOLIN
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 1:141 LONGWATER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1620
Mailing Address - Country:US
Mailing Address - Phone:781-792-4136
Mailing Address - Fax:781-878-6750
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-624-8000
Practice Address - Fax:781-878-6750
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246085207R00000X
FLME 88741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268992800Medicaid
U2114ZMedicare ID - Type Unspecified