MEDICARE: SHELDON EHRENZWEIG PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	419	MA

General Provider Information

NPI Number	:	1265422232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELDON EHRENZWEIG PA

Provider Business Mailing Address
First Line	:	110 LIBERTY ST
Second Line	:	SIGNATURE HEALTHCARE
City	:	BROCKTON
State	:	MA
Zip	:	02301-0000
Country	:	US
Telephone Number	:	508-894-0400
Fax Number	:	508-894-0628

Provider Business Practice Location Address
First Line	:	110 LIBERTY ST
Second Line	:	SIGNATURE HEALTHCARE
City	:	BROCKTON
State	:	MA
Zip	:	02301-0000
Country	:	US
Telephone Number	:	508-894-0400
Fax Number	:	508-894-0628

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	02/01/2016

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