=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366726259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIE PHYSICIANS NETWORK-UPMC,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2011
-----------------------------------------------------
Last Update Date | 04/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1325 W 26TH ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16508-1469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-647-0943
-----------------------------------------------------
Fax | 412-647-4050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2861 W 26TH ST SUITE 2
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16506-3064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-835-3751
-----------------------------------------------------
Fax | 814-835-3755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR.DIRECTOR
-----------------------------------------------------
Name | MR. MARK EHALT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 412-647-0943
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207XX0004X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------