Provider Demographics
NPI:1376991059
Name:ERICKSON, RUSSELL IRVING CARL IV (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:IRVING CARL
Last Name:ERICKSON
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARL
Other - Middle Name:
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:46 BARRA RD
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9459
Mailing Address - Country:US
Mailing Address - Phone:207-282-5509
Mailing Address - Fax:
Practice Address - Street 1:46 BARRA RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9459
Practice Address - Country:US
Practice Address - Phone:207-282-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMS245352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology