Provider Demographics
NPI:1043289994
Name:ERICKSON, MELISSA G (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:G
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 VICTORY PARKWAY
Mailing Address - Street 2:PAYOR ENROLLMENT
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-585-5507
Mailing Address - Fax:
Practice Address - Street 1:68 CAVALIER BOULEVARD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1645
Practice Address - Country:US
Practice Address - Phone:859-594-1010
Practice Address - Fax:859-372-5004
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.120003207Q00000X
KY47497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200810110Medicaid
INDC3600OtherRAILROAD GROUP
INP00416673OtherRAILROAD INDIVIDUAL
KYK160000Medicare PIN
INDC3600OtherRAILROAD GROUP
I51152Medicare UPIN