Provider Demographics
NPI:1417247123
Name:MEDICAL ASSOCIATES OF ERIE
Entity Type:Organization
Organization Name:MEDICAL ASSOCIATES OF ERIE
Other - Org Name:WEST LAKE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:STYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-868-2504
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3435 W LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3661
Practice Address - Country:US
Practice Address - Phone:814-835-6633
Practice Address - Fax:814-835-6637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101066458Medicaid
PA096315Medicare PIN