Provider Demographics
NPI:1003250655
Name:BOSTROM, ERIK (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:BOSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BUNKER HILL DR
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1865
Mailing Address - Country:US
Mailing Address - Phone:218-927-2157
Mailing Address - Fax:
Practice Address - Street 1:200 BUNKER HILL DR
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1865
Practice Address - Country:US
Practice Address - Phone:218-927-2157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN59333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1003250655Medicaid