Healthcare Provider Details

I. General information

NPI: 1740222603
Provider Name (Legal Business Name): ERIC TRIPP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 HOLY CROSS PARKWAY
MISHAWAKA IN
46545
US

IV. Provider business mailing address

1234 NAPIER AVE
SAINT JOSEPH MI
49085-2112
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-5000
  • Fax: 574-335-0760
Mailing address:
  • Phone: 269-983-8172
  • Fax: 269-985-4535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301102003
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01040707
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: