1124228374 NPI number — DR. ERIC JACOB STERN M.D

Table of content: DR. ERIC JACOB STERN M.D (NPI 1124228374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124228374 NPI number — DR. ERIC JACOB STERN M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STERN
Provider First Name:
ERIC
Provider Middle Name:
JACOB
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

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:
1124228374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 418283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-8283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-558-1544
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 RESERVOIR ROAD, NW
Provider Second Line Business Practice Location Address:
GEORGETOWN UNIVERSITY HOSPITAL, 2-PHC
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-444-8262
Provider Business Practice Location Address Fax Number:
202-444-7161
Provider Enumeration Date:
07/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0208X , with the licence number:  MD037992 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1124228374 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0523722400 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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