Basic Information
| Provider Information | |||||||||
| NPI: | 1720091879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YERKA | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD, LP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 288 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562580288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5079299411 | ||||||||
| FaxNumber: | 5074012568 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 E BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073372923 | ||||||||
| FaxNumber: | 5073372926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/11/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP4390 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2281409 | 01 | MN | UNITED HEALTHCARE | OTHER | 50M21YE | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 680015067 | 01 | MN | RR MEDICARE | OTHER | 1032344 | 01 | MN | PREFERRED ONE | OTHER | 143659 | 01 | MN | UCARE | OTHER | 61-53867 | 01 | MN | MEDICA | OTHER | HP37854 | 01 | MN | HEALTH PARTNERS | OTHER | 156835300 | 05 | MN | MEDICAID | 30281 | 01 | MN | SIOUX VALLEY HEALTH | OTHER |