Basic Information
| Provider Information | |||||||||
| NPI: | 1982624763 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERICKSON HEALTH MEDICAL GROUP OF ILLINOIS PC | ||||||||
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| OtherOrganizationName: | SEDGEBROOK MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 MAIDEN CHOICE LN | ||||||||
| Address2: | |||||||||
| City: | CATONSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212285968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104022257 | ||||||||
| FaxNumber: | 4104022264 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 AUDUBON WAY | ||||||||
| Address2: | |||||||||
| City: | LINCOLNSHIRE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600693811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478762200 | ||||||||
| FaxNumber: | 8477930281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | NARRETT | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP, CMO | ||||||||
| AuthorizedOfficialTelephone: | 4104022257 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 364SP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 207QG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 364SG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4932996 | 01 | BCBS OF IL | OTHER |