Provider Demographics
NPI:1992866990
Name:ROBERT ERICKSON DO AND JENNIFER ERICKSON DO LLC
Entity Type:Organization
Organization Name:ROBERT ERICKSON DO AND JENNIFER ERICKSON DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:716-667-2673
Mailing Address - Street 1:3671 SOUTHWESTERN BLVD ST 213
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-667-2673
Mailing Address - Fax:716-662-5226
Practice Address - Street 1:3671 SOUTHWESTERN BLVD ST 213
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127
Practice Address - Country:US
Practice Address - Phone:716-667-2673
Practice Address - Fax:716-662-5226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175824207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01781759Medicaid
E42071Medicare UPIN
NY01781759Medicaid
E45126Medicare UPIN