Provider Demographics
NPI:1568480366
Name:ERICKSON, EVELYN J (MD)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:J
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 12TH ST N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-253-7257
Mailing Address - Fax:320-251-2938
Practice Address - Street 1:3701 12TH ST N
Practice Address - Street 2:SUITE 100
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-7257
Practice Address - Fax:320-251-2938
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN373462086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN145719500Medicaid
111011OtherUCARE
1006655OtherP-ONE
6T195EROtherBCBS
249000019OtherMETRAHEALTH (MPIN)
1301024OtherMEDICA
145719500OtherNEW MA PROVIDER
MN145719500Medicaid