1356337471 NPI number — DR. THOMAS MICHAEL ERICHSON O.D.

Table of content: DR. THOMAS MICHAEL ERICHSON O.D. (NPI 1356337471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356337471 NPI number — DR. THOMAS MICHAEL ERICHSON O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICHSON
Provider First Name:
THOMAS
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1356337471
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 BUSHWICK RD STE B
Provider Second Line Business Mailing Address:
LAGRANGE PROFESSIONAL BUILDING
Provider Business Mailing Address City Name:
POUGHKEEPSIE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12603-3839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-471-1147
Provider Business Mailing Address Fax Number:
845-473-1849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BUSHWICK RD STE B
Provider Second Line Business Practice Location Address:
LAGRANGE PROFESSIONAL BUILDING
Provider Business Practice Location Address City Name:
POUGHKEEPSIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12603-3839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-471-1147
Provider Business Practice Location Address Fax Number:
845-473-1849
Provider Enumeration Date:
09/23/2005

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: 152W00000X , with the licence number:  TUV004036 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2C9390 . This is a "HEALTHNET PROV #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 141816850 . This is a "POMCO PROV #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2218214 . This is a "AETNA HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: C37061 . This is a "EMPIRE BC/BS PROV #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P1954861 . This is a "OXFORD PROV #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10034123 GRP6170 . This is a "CDPHP PROV #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 597024 . This is a "MVP PROV. #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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