Basic Information
| Provider Information | |||||||||
| NPI: | 1548441249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | ERIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12400 S HARLEM AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631440 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2748 CATON FARM RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604351309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156090554 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2007 | ||||||||
| LastUpdateDate: | 11/21/2007 | ||||||||
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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 | 225500000X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist |
ID Information
| ID | Type | State | Issuer | Description | 7454077 | 01 | IL | AETNA | OTHER | 01622333 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |