Provider Demographics
NPI:1780217646
Name:MEDICAL ASSOCIATES OF ERIE
Entity Type:Organization
Organization Name:MEDICAL ASSOCIATES OF ERIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-868-2507
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:814-868-2507
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:5401 PEACH ST STE 3500
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2601
Practice Address - Country:US
Practice Address - Phone:814-868-2179
Practice Address - Fax:814-868-2346
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL ASSOCIATES OF ERIE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010664580027Medicaid