Basic Information
| Provider Information | |||||||||
| NPI: | 1457443673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 SAINT JOHNS BLVD | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512325354 | ||||||||
| FaxNumber: | 6512325217 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SAINT JOHNS BLVD | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512325354 | ||||||||
| FaxNumber: | 6512325217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 34586 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P2900X | 34586 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0VN2576 | 05 | VT | MEDICAID |