Healthcare Provider Details

I. General information

NPI: 1952338808
Provider Name (Legal Business Name): M ERICKSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N. MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

100 N. MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-3578
  • Fax:
Mailing address:
  • Phone: 801-662-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number363155-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: