Provider Demographics
NPI:1740222603
Name:TRIPP, ERIC (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:TRIPP
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 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-983-8172
Mailing Address - Fax:269-985-4535
Practice Address - Street 1:5215 HOLY CROSS PARKWAY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-335-5000
Practice Address - Fax:574-335-0760
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102003208M00000X
IN01040707207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100328400HMedicaid
IN000000334836OtherBCBS
IN000000687861OtherBCBS
IN100328400Medicaid
INP00943362Medicare PIN
IN000000687861OtherBCBS
IN187710HMedicare PIN
INM400032698Medicare PIN
INP00155406Medicare PIN