Provider Demographics
NPI:1609985407
Name:CARL F. ERICKSON, MD PA
Entity Type:Organization
Organization Name:CARL F. ERICKSON, MD PA
Other - Org Name:PEMBROKE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-641-6559
Mailing Address - Street 1:9711 HUEBNER
Mailing Address - Street 2:BLDG 2
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3163
Mailing Address - Country:US
Mailing Address - Phone:210-641-6559
Mailing Address - Fax:210-699-9968
Practice Address - Street 1:9711 HUEBNER
Practice Address - Street 2:BLDG 2
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3163
Practice Address - Country:US
Practice Address - Phone:210-641-6559
Practice Address - Fax:210-699-9968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0002HDOtherBC/BS GROUP
TX102522303Medicaid
TX5041089OtherAETNA
TX150274201Medicaid
TX8F3210OtherBC/BS INDIVIDUAL
TX102522303Medicaid
TXE39475Medicare UPIN
TX8607B0Medicare ID - Type UnspecifiedINDIVIDUAL