Basic Information
| Provider Information | |||||||||
| NPI: | 1992796676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14909 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554140909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Practice Location | |||||||||
| Address1: | 5705 W OLD SHAKOPEE RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554373126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 46543 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1041176 | 01 | PREFERRED ONE | OTHER | HP42391 | 01 | HEALTH PARTNERS | OTHER | 2900346 | 01 | MEDICA HEALTH PLANS | OTHER | 506R1ER(PL) | 01 | BLUE CROSS BLUE SHIELD | OTHER | 660954600 | 01 | MEDICAL ASSISTANCE | OTHER | 131474 | 01 | U-CARE | OTHER | 2157898 | 01 | ARAZ GROUP/AMERICAS PPO | OTHER | 386K6ER(RC) | 01 | BLUE CROSS BLUE SHIELD | OTHER | P00147329 | 01 | RR MEDICARE | OTHER |