Provider Demographics
NPI:1962881235
Name:ERICKSON, MARY ELOISE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELOISE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-3000
Mailing Address - Fax:
Practice Address - Street 1:7650 ZANE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3151
Practice Address - Country:US
Practice Address - Phone:612-873-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN65640208000000X, 207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics