Healthcare Provider Details

I. General information

NPI: 1518957190
Provider Name (Legal Business Name): LARS ERICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 OAK AVE
WORCESTER MA
01605-2752
US

IV. Provider business mailing address

33 OAK AVE
WORCESTER MA
01605-2752
US

V. Phone/Fax

Practice location:
  • Phone: 508-757-7300
  • Fax: 508-757-7900
Mailing address:
  • Phone: 508-757-7300
  • Fax: 800-757-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number59113
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3107523
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: