Basic Information
| Provider Information | |||||||||
| NPI: | 1073598355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23968 NORTH 83RD LANE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239359328 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13677 W MCDOWELL RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853952635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238821500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 03/27/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2438 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 860373636 | 01 | AZ | HUMANA | OTHER | AW1436 | 01 | AZ | HEALTHNET | OTHER | 3981220 | 01 | AZ | EVERCARE | OTHER | 453051001 | 01 | AZ | GROUP HEALTH | OTHER | 758013 | 05 | AZ | MEDICAID |