1952338808 NPI number — M ERICKSEN MD

Table of content: M ERICKSEN MD (NPI 1952338808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952338808 NPI number — M ERICKSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSEN
Provider First Name:
M
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1952338808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N. MARIO CAPECCHI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84113-1103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-662-3578
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N. MARIO CAPECCHI DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84113-1103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-662-3578
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2006

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: 207L00000X , with the licence number:  363155-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 77988 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 806196700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120083600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36315512000001 . This is a "BCBS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 693497 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 878407 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100504905 . This is a "FIRST HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 219176 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 78899 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 0153221 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 870280408MTY . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: PRA06245 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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