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General NPI Number Information
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NPI Number | 1174902498
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Entity Type | Individual
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Provider Name | STEPHANUS ERIC HARYADI M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/19/2015
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Last Update Date | 02/03/2021
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Provider Practice Location Address
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Address Line | 315 E MAIN ST
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City | ORWELL
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State | OH
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Zip | 44076-9590
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Country | US
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Telephone | 440-437-6222
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Fax | 440-437-1022
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Provider Business Mailing Address
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Address Line | 8055 MAYFIELD RD STE 105
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City | CHESTERLAND
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State | OH
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Zip | 44026-2447
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 35.135310
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License Number State | OH
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