Provider Demographics
NPI:1689699563
Name:M.D. ERA, LLC
Entity Type:Organization
Organization Name:M.D. ERA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:CRT, RCP
Authorized Official - Phone:512-554-8669
Mailing Address - Street 1:6521 BURNET LN
Mailing Address - Street 2:SUITE 108
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2848
Mailing Address - Country:US
Mailing Address - Phone:512-454-2727
Mailing Address - Fax:512-454-2728
Practice Address - Street 1:6521 BURNET LN
Practice Address - Street 2:SUITE 108
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-2848
Practice Address - Country:US
Practice Address - Phone:512-454-2727
Practice Address - Fax:512-454-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0091015332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX532275OtherBCBSTX PPO
TX532275OtherBCBSTX PPO
TX=========OtherTRICARE
TX=========OtherTRICARE