=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467938894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC RYAN STILL PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 12/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 E 68TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-620-1764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 S OXFORD ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11217-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-620-1764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0801X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Trauma Physician
-----------------------------------------------------
License Number | TBD
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------