Provider Demographics
NPI:1851561732
Name:M. L. ERICKSON, MD, LLC
Entity Type:Organization
Organization Name:M. L. ERICKSON, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-414-3500
Mailing Address - Street 1:6370 W UNION HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7136
Mailing Address - Country:US
Mailing Address - Phone:623-414-3500
Mailing Address - Fax:623-455-9214
Practice Address - Street 1:6370 W UNION HILLS DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7136
Practice Address - Country:US
Practice Address - Phone:623-414-3500
Practice Address - Fax:623-455-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28384207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ28384Medicaid
AZ512774Medicaid
AZZ75660Medicare PIN