Healthcare Provider Details

I. General information

NPI: 1336706571
Provider Name (Legal Business Name): ETHAN MICHAEL YERGER RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E VINE ST
SALISBURY MD
21804-5531
US

IV. Provider business mailing address

1681 CHOPTANK RD
MIDDLETOWN DE
19709-9043
US

V. Phone/Fax

Practice location:
  • Phone: 443-358-6445
  • Fax:
Mailing address:
  • Phone: 302-893-9845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX4709
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: