Provider Demographics
NPI:1518967751
Name:KULSTAD, ERIK B (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIK
Middle Name:B
Last Name:KULSTAD
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 1:1505 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2855
Mailing Address - Country:US
Mailing Address - Phone:708-786-2900
Mailing Address - Fax:
Practice Address - Street 1:1501 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1732
Practice Address - Country:US
Practice Address - Phone:773-257-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-109728-2Medicaid
ILK08461/357801Medicare ID - Type Unspecified
IL036-109728-2Medicaid