Provider Demographics
NPI:1073516035
Name:ERICKSON, KENT EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:EDWIN
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1024 LANE ST
Mailing Address - Street 2:ERICKSON MEDICAL CLINIC
Mailing Address - City:CLAY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67432-2211
Mailing Address - Country:US
Mailing Address - Phone:785-632-6415
Mailing Address - Fax:785-632-2309
Practice Address - Street 1:409 LINCOLN AVE
Practice Address - Street 2:ERICKSON MEDICAL CLINIC, LLC
Practice Address - City:CLAY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67432-2907
Practice Address - Country:US
Practice Address - Phone:785-777-2622
Practice Address - Fax:785-777-2623
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2016-06-16
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Provider Licenses
StateLicense IDTaxonomies
KS22435207Q00000X
KS04-22435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100208950AMedicaid
KS100208950AMedicaid
KSR90912Medicare UPIN
KS003863Medicare PIN