Basic Information
Provider Information | |||||||||
NPI: | 1174933048 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERICSON | ||||||||
FirstName: | KYLE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2350 CHARNEY RD | ||||||||
Address2: |   | ||||||||
City: | UNIVERSITY HEIGHTS | ||||||||
State: | OH | ||||||||
PostalCode: | 441183720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162132169 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 29000 CENTER RIDGE RD STE 400 | ||||||||
Address2: |   | ||||||||
City: | WESTLAKE | ||||||||
State: | OH | ||||||||
PostalCode: | 441455219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4408358000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2014 | ||||||||
LastUpdateDate: | 02/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 57.026312 | OH | N |   | Allopathic & Osteopathic Physicians | Urology |   | 390200000X |   | IL | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208800000X | 35.142520 | OH | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 0454660 | 05 | OH |   | MEDICAID |