Basic Information
| Provider Information | |||||||||
| NPI: | 1952327553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICSON | ||||||||
| FirstName: | KEELYN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 SW MULVANE ST | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853549591 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 823 SW MULVANE ST | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666061764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853549591 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 04-30248 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 200383540B | 05 | KS | MEDICAID | 067349 | 01 | KS | MEDICARE PTAN | OTHER |