Provider Demographics
NPI:1457522369
Name:ORTHOPAEDIC & SPORTS MEDICINE OF ERIE PC
Entity Type:Organization
Organization Name:ORTHOPAEDIC & SPORTS MEDICINE OF ERIE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-454-8287
Mailing Address - Street 1:300 STATE ST
Mailing Address - Street 2:#400A
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1427
Mailing Address - Country:US
Mailing Address - Phone:814-454-8287
Mailing Address - Fax:814-454-8470
Practice Address - Street 1:300 YORK ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-1420
Practice Address - Country:US
Practice Address - Phone:814-664-9866
Practice Address - Fax:814-454-8470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012321160003Medicaid
PA0012321160003Medicaid