Healthcare Provider Details

I. General information

NPI: 1568447399
Provider Name (Legal Business Name): ERIC JONATHAN FRIEDMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S 4TH ST
LEAVENWORTH KS
66048-5014
US

IV. Provider business mailing address

4101 S 4TH ST
LEAVENWORTH KS
66048-5014
US

V. Phone/Fax

Practice location:
  • Phone: 913-682-2000
  • Fax:
Mailing address:
  • Phone: 913-682-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0101252730
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101252730
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberD0055111
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: