Provider Demographics
NPI:1891751657
Name:ERIESIDE MEDICAL GROUP
Entity Type:Organization
Organization Name:ERIESIDE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-269-7483
Mailing Address - Street 1:38429 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7009
Mailing Address - Country:US
Mailing Address - Phone:440-946-9200
Mailing Address - Fax:
Practice Address - Street 1:38429 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7009
Practice Address - Country:US
Practice Address - Phone:440-946-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-052285D207Q00000X
OH35-06-5285H207R00000X
OH34-003413F207R00000X
35-06-1390M2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC02730Medicare UPIN
OHA16908Medicare UPIN
OHF59340Medicare UPIN
OHF30444Medicare UPIN