Basic Information
| Provider Information | |||||||||
| NPI: | 1689662124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | KIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 W ALLENS LN | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191192807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674559156 | ||||||||
| FaxNumber: | 2127943182 | ||||||||
| Practice Location | |||||||||
| Address1: | 1275 YORK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100656007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126393023 | ||||||||
| FaxNumber: | 2127943182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD417093 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0018834220001 | 05 | PA | MEDICAID |