1114920972 NPI number — SCOTT W WYRICK M.D.

Table of content: SCOTT W WYRICK M.D. (NPI 1114920972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114920972 NPI number — SCOTT W WYRICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYRICK
Provider First Name:
SCOTT
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114920972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 POTOMAC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-3513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-792-3787
Provider Business Mailing Address Fax Number:
903-792-0446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 POTOMAC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-3513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-3787
Provider Business Practice Location Address Fax Number:
903-792-0446
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  J2424 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 80451Y . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: T0120358 . This is a "CONTROLLED SUBSTANCES REG" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 070016709 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 150168601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8312J1 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 99096 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 148032001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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