Healthcare Provider Details

I. General information

NPI: 1760696140
Provider Name (Legal Business Name): ERICA TYLER GHOSH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N # S2-824
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

55 LAKE AVE N # S2-824
WORCESTER MA
01655-0002
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-5381
  • Fax: 508-334-5586
Mailing address:
  • Phone: 508-856-5381
  • Fax: 508-334-5586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number240529
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110085789A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: