Basic Information
| Provider Information | |||||||||
| NPI: | 1528070513 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VERN E ERICKSON MD PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ERICKSON MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 7TH ST W | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187327760 | ||||||||
| FaxNumber: | 2187327334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | VERN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2187327760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 120354100 | 05 | MN | MEDICAID | 82065ER | 01 | MN | BCBS | OTHER |