1427148485 NPI number — DR. LEIF E ERICKSON OD

Table of content: DR. LEIF E ERICKSON OD (NPI 1427148485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427148485 NPI number — DR. LEIF E ERICKSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
LEIF
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1427148485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15601 RAILROAD ST
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54843-6527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-634-8616
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15601 RAILROAD ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
HAYWARD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54843-6527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-634-8616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

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: 152W00000X , with the licence number:  1306-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22704 . This is a "SECURITY HEALTH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38568600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4U216ER . This is a "ATRIUM" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 11727 . This is a "NVA & PROVANTAGE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 22-00507 . This is a "MEDICA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38568600 . This is a "GROUP HEALTH" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 26011R , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 87217 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1001441 . This is a "PREFERRED ONE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38568600 . This is a "HEALTH RISK" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39-1131290 . This is a "SELECT CARE & CBSA" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 46988 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 87213 . This is a "TRI CARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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