Provider Demographics
NPI:1194509638
Name:SUTHERLAND, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 N PENNELL RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5520
Mailing Address - Country:US
Mailing Address - Phone:610-891-0114
Mailing Address - Fax:610-891-0559
Practice Address - Street 1:28 N PENNELL RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5520
Practice Address - Country:US
Practice Address - Phone:610-891-0114
Practice Address - Fax:610-891-0559
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty