Provider Demographics
NPI:1033173125
Name:ERICKSON, KURT W (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:W
Last Name:ERICKSON
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 1:13011 S 104TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1508
Mailing Address - Country:US
Mailing Address - Phone:708-478-3600
Mailing Address - Fax:708-478-3552
Practice Address - Street 1:11560 S KEDZIE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MERRIONETTE PARK
Practice Address - State:IL
Practice Address - Zip Code:60803-4517
Practice Address - Country:US
Practice Address - Phone:708-824-1114
Practice Address - Fax:708-824-9341
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073183207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL236550OtherMEDICARE GROUP
ILCD8033OtherRAILROAD MEDICARE GROUP PTAN NUMBER
ILCN2703OtherRAILROAD MEDICARE GROUP PTAN NUMBER
IL036073183Medicaid
IL060056644OtherRAILROAD MEDICARE WILL
IL236551OtherMEDICARE GROUP
IL416810OtherMEDICARE GROUP
IL1508810086OtherGROUP NPI
01621208OtherBLUE CROSS BLUE SHIELD
IL060042344OtherRAILROAD MEDICARE COOK
IL060042344OtherRAILROAD MEDICARE COOK
IL1508810086OtherGROUP NPI
ILCD8033OtherRAILROAD MEDICARE GROUP PTAN NUMBER
C45227Medicare UPIN