Healthcare Provider Details

I. General information

NPI: 1891751657
Provider Name (Legal Business Name): ERIESIDE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38429 LAKE SHORE BLVD
WILLOUGHBY OH
44094-7009
US

IV. Provider business mailing address

38429 LAKE SHORE BLVD
WILLOUGHBY OH
44094-7009
US

V. Phone/Fax

Practice location:
  • Phone: 440-946-9200
  • Fax:
Mailing address:
  • Phone: 440-946-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-052285D
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-06-5285H
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34-003413F
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number35-06-1390M
License Number State

VIII. Authorized Official

Name: DR. WINSTON HO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 440-269-7483