Healthcare Provider Details

I. General information

NPI: 1346627015
Provider Name (Legal Business Name): GRANT ERICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

IV. Provider business mailing address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberD0092401
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0092401
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: