=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457625709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEID SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2012
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 W OKLAHOMA AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215-4330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-649-6000
-----------------------------------------------------
Fax | 414-649-1325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 71807
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23255-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-350-2889
-----------------------------------------------------
Fax | 804-612-5201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAIRO A ERASO ZAMARO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 414-364-3037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 50877-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------