Provider Demographics
NPI:1972750743
Name:ERICSON, ERIC JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JAMES
Last Name:ERICSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 W 177TH ST
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2184
Mailing Address - Country:US
Mailing Address - Phone:708-799-6799
Mailing Address - Fax:708-799-6991
Practice Address - Street 1:3330 W 177TH ST
Practice Address - Street 2:SUITE 3C
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2184
Practice Address - Country:US
Practice Address - Phone:708-799-6799
Practice Address - Fax:708-799-6991
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250509332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125050933OtherMEDICAL LICENSE NUMBER