Provider Demographics
NPI: | 1134321052 |
---|---|
Name: | HOLMES, ERIC EDWIN |
Entity Type: | Individual |
Prefix: | |
First Name: | ERIC |
Middle Name: | EDWIN |
Last Name: | HOLMES |
Suffix: | |
Gender: | M |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2233 STATE ROUTE 86 |
Mailing Address - Street 2: | P.O. BOX 1380 |
Mailing Address - City: | SARANAC LAKE |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 12983-5644 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 518-897-2317 |
Mailing Address - Fax: | 518-897-2423 |
Practice Address - Street 1: | 2233 STATE ROUTE 86 |
Practice Address - Street 2: | |
Practice Address - City: | SARANAC LAKE |
Practice Address - State: | NY |
Practice Address - Zip Code: | 12983-5644 |
Practice Address - Country: | US |
Practice Address - Phone: | 518-897-2317 |
Practice Address - Fax: | 518-897-2423 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-06-04 |
Last Update Date: | 2007-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 023196 | 225100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 00363213 | Medicaid | |
NY | 023196 | Other | LICENSE |
NY | 33U079 | Medicare ID - Type Unspecified | HOSPITAL MCR SWING BED # |
NY | 00363213 | Medicaid |