=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255531372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERICSON HAND AND NERVE CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2007
-----------------------------------------------------
Last Update Date | 01/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6100 219TH ST SW SUITE 540
-----------------------------------------------------
City | MOUNTLAKE TERRACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98043-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-776-4444
-----------------------------------------------------
Fax | 425-328-1540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6100 219TH ST SW SUITE 540
-----------------------------------------------------
City | MOUNTLAKE TERRACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98043-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-776-4444
-----------------------------------------------------
Fax | 425-328-1540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | WILLIAM BURTON ERICSON JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 425-776-4444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | MD00044072
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------