Basic Information
| Provider Information | |||||||||
| NPI: | 1467558452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EROSSY | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24651 CENTER RIDGE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441455635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408955056 | ||||||||
| FaxNumber: | 4403332935 | ||||||||
| Practice Location | |||||||||
| Address1: | 26016 DETROIT RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | WESTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441452477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406140626 | ||||||||
| FaxNumber: | 4406140625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 51325 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0756883 | 05 | OH | MEDICAID |