1528070513 NPI number — VERN E ERICKSON MD PA

Table of content: (NPI 1528070513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528070513 NPI number — VERN E ERICKSON MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERN E ERICKSON MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1528070513
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3920 13TH AVE E
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
HIBBING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55746-3675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-263-7540
Provider Business Mailing Address Fax Number:
866-732-0699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 7TH ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56470-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-732-7760
Provider Business Practice Location Address Fax Number:
218-732-7334
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
VERN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-732-7760

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 120354100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82065ER . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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