Provider Demographics
NPI:1013903418
Name:ERVIN, SEAN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:EDWARD
Last Name:ERVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501071207R00000X
NC2061599A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
140K6OtherBCBS
NC5901865Medicaid
WV3810003147Medicaid
7701646OtherAETNA
VA10197163Medicaid
MA110089907AMedicaid
182869OtherMEDCOST
806778OtherPARTNERS
SCQ0107DMedicaid
NC2046165Medicare PIN
MA002365901Medicare PIN
7701646OtherAETNA