Provider Demographics
NPI:1083783823
Name:ERICKSON, TY BOLTON (MD)
Entity Type:Individual
Prefix:DR
First Name:TY
Middle Name:BOLTON
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 1:2184 CHANNING WAY PMB #135
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8034
Mailing Address - Country:US
Mailing Address - Phone:208-552-6914
Mailing Address - Fax:208-552-4973
Practice Address - Street 1:808 PANCHERI DRIVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3344
Practice Address - Country:US
Practice Address - Phone:208-552-6900
Practice Address - Fax:208-552-4973
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6628207V00000X
UT6388670-1205207V00000X, 207VF0040X
IDM6628207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003678800Medicaid
ID1130793Medicare PIN
IDE87828Medicare UPIN
ID003678800Medicaid
1130793Medicare PIN