1992796676 NPI number — JASON M ERICKSON MD

Table of content: JASON M ERICKSON MD (NPI 1992796676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992796676 NPI number — JASON M ERICKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
JASON
Provider Middle Name:
M
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:
1992796676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14909
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55414-0909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-871-1145
Provider Business Mailing Address Fax Number:
612-870-5491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5705 W OLD SHAKOPEE RD STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55437-3126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-871-1145
Provider Business Practice Location Address Fax Number:
612-870-5491
Provider Enumeration Date:
11/02/2005

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: 207RG0100X , with the licence number:  46543 , 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: 1041176 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP42391 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2900346 . This is a "MEDICA HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 506R1ER(PL) . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 660954600 . This is a "MEDICAL ASSISTANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 131474 . This is a "U-CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2157898 . This is a "ARAZ GROUP/AMERICAS PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 386K6ER(RC) . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00147329 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com