Basic Information
| Provider Information | |||||||||
| NPI: | 1871975490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5742376069 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 N MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746477477 | ||||||||
| FaxNumber: | 5746473655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2015 | ||||||||
| LastUpdateDate: | 07/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11018173A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01080336A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 300014890 | 05 | IN | MEDICAID |