Provider Demographics
NPI:1619931185
Name:ERICKSON, KEITH J (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:J
Last Name:ERICKSON
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 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:844-374-8893
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:13100 WAYZATA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1810
Practice Address - Country:US
Practice Address - Phone:952-206-2040
Practice Address - Fax:952-206-2041
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN361442084P0800X
ND62102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4T606EROtherBLUE CROSS BLUE SHIELD
MN103765000Medicaid
ND12327OtherBLUE CROSS BLUE SHIELD
ND17911Medicaid
ND12327OtherBLUE CROSS BLUE SHIELD