Provider Demographics
NPI:1689662124
Name:ERICKSON, LEE KIM (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:KIM
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 1:535 W ALLENS LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2807
Mailing Address - Country:US
Mailing Address - Phone:267-455-9156
Mailing Address - Fax:212-794-3182
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-3023
Practice Address - Fax:212-794-3182
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018834220001Medicaid
PA054858R7RMedicare PIN
PA0018834220001Medicaid