Provider Demographics
NPI:1306848122
Name:ERICKSON, BERNARD RUDOLPH (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:RUDOLPH
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 1:1200 SIXTH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35376207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
771742OtherARAZ GROUP AMERICAS PPO
2114046OtherFIRST HEALTH PLAN
2500065OtherMEDICA HEALTH PLANS
HP26067OtherHEALTH PARTNERS
106328OtherU-CARE
MN695582700Medicaid
42Q68EROtherBLUE CROSS BLUE SHIELD
695582700OtherMEDICAL ASSISTANCE MA
060046908OtherRR MEDICARE CU0204
1016077OtherPREFERRED ONE
2500065OtherMEDICA HEALTH PLANS
2114046OtherFIRST HEALTH PLAN