Basic Information
| Provider Information | |||||||||
| NPI: | 1841279833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STORVICK | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E MAIN ST MANKATO CLINIC LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1230 E MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC AT MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 36201 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0401913 | 01 | MEDICA MN | OTHER | 121152 | 01 | UCARE MN | OTHER | 415863600 | 05 | MN | MEDICAID | 41084933956001C033 | 01 | CHAMPUS | OTHER | 938472 | 05 | IA | MEDICAID | 110103563 | 01 | RR MEDICARE | OTHER | 2M646ST | 01 | BCBS MN | OTHER | NA2951023861 | 01 | PREFERRED ONE MN | OTHER | HP25686 | 01 | HEALTH PARTNERS MN | OTHER | 887698 | 01 | AMERICAS PPO MN | OTHER |