Provider Demographics
NPI:1255609822
Name:ESR MEDICATION ASSISTED TREATMENT
Entity type:Organization
Organization Name:ESR MEDICATION ASSISTED TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MR
Authorized Official - First Name:RAUN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SKYRM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-773-3544
Mailing Address - Street 1:405 TALLMADGE RD
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-3362
Mailing Address - Country:US
Mailing Address - Phone:330-773-3544
Mailing Address - Fax:330-773-3698
Practice Address - Street 1:405 TALLMADGE RD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-3362
Practice Address - Country:US
Practice Address - Phone:330-773-3544
Practice Address - Fax:330-773-3698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty