Provider Demographics
NPI:1174933048
Name:ERICSON, KYLE J (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:J
Last Name:ERICSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 CHARNEY RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-3720
Mailing Address - Country:US
Mailing Address - Phone:216-213-2169
Mailing Address - Fax:
Practice Address - Street 1:29000 CENTER RIDGE RD STE 400
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5219
Practice Address - Country:US
Practice Address - Phone:440-835-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.026312208800000X
IL390200000X
OH35.142520208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0454660Medicaid