1497367130 NPI number — BROWNSTONE HEALTHCARE LLC

Table of content: DR. ERICA LEE DITKOFF M.D. (NPI 1285165589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497367130 NPI number — BROWNSTONE HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROWNSTONE HEALTHCARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497367130
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12755 ORLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACK JACK
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63033-4614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-565-4708
Provider Business Mailing Address Fax Number:
314-741-1258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12755 ORLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACK JACK
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63033-4614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-565-4708
Provider Business Practice Location Address Fax Number:
314-741-1258
Provider Enumeration Date:
08/22/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAVIDSON
Authorized Official First Name:
CHESTER
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OPERATING MANAGER
Authorized Official Telephone Number:
314-565-3750

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)