1669555843 NPI number — SUSAN LEE ERICKSON MD

Table of content: SUSAN LEE ERICKSON MD (NPI 1669555843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669555843 NPI number — SUSAN LEE ERICKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
SUSAN
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1669555843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2497 7TH AVE E
Provider Second Line Business Mailing Address:
BHSI LLC SUITE 101
Provider Business Mailing Address City Name:
NORTH ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109-2496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-769-6437
Provider Business Mailing Address Fax Number:
651-769-6426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 S MARSHALL RD
Provider Second Line Business Practice Location Address:
BHSI LLC SUITE 250
Provider Business Practice Location Address City Name:
SHAKOPEE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55379-2666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-769-6500
Provider Business Practice Location Address Fax Number:
651-769-6549
Provider Enumeration Date:
10/23/2006

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: 2084P0800X , with the licence number:  37115 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 695326300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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