Healthcare Provider Details

I. General information

NPI: 1225105596
Provider Name (Legal Business Name): ERIC DOUGLAS ERVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 3RD ST SUITE 180
HENDERSON KY
42420-2993
US

IV. Provider business mailing address

2000 N ELM ST STE 1B
HENDERSON KY
42420-2385
US

V. Phone/Fax

Practice location:
  • Phone: 270-827-3573
  • Fax: 270-827-1250
Mailing address:
  • Phone: 270-844-8144
  • Fax: 270-844-8145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35996
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: