1043289713 NPI number — JOHN E ERICKSON MD

Table of content: JOHN E ERICKSON MD (NPI 1043289713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043289713 NPI number — JOHN E ERICKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
JOHN
Provider Middle Name:
E
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:
1043289713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 FODEN RD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-2327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-828-0361
Provider Business Mailing Address Fax Number:
207-874-1483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
84 MARGINAL WAY
Provider Second Line Business Practice Location Address:
SUITE 700
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-774-5816
Provider Business Practice Location Address Fax Number:
207-523-8597
Provider Enumeration Date:
03/16/2006

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: 207R00000X , with the licence number:  012994 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1041229 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 270190099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010560 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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