Basic Information
| Provider Information | |||||||||
| NPI: | 1316136278 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERICKSON RETIREMENT COMMUNITIES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 701 MAIDEN CHOICE LN | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212285968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104022261 | ||||||||
| FaxNumber: | 4104022264 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 ERICKSON DR | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605634164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303001126 | ||||||||
| FaxNumber: | 6303001394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THORNE | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | EMPLOYEE HEALTH MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4104022261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 2083X0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.