Provider Demographics
NPI:1558676957
Name:ERICKSON SURGICAL CONSULTING PLLC
Entity Type:Organization
Organization Name:ERICKSON SURGICAL CONSULTING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:BOLTON
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-727-2672
Mailing Address - Street 1:63 E 11400 S
Mailing Address - Street 2:SUITE 252
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-6705
Mailing Address - Country:US
Mailing Address - Phone:801-727-2672
Mailing Address - Fax:801-727-2682
Practice Address - Street 1:10011 CENTENNIAL PKWY
Practice Address - Street 2:SUITE 150
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4156
Practice Address - Country:US
Practice Address - Phone:801-727-2672
Practice Address - Fax:801-727-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63886701205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000072120Medicare PIN