1548233703 NPI number — DR. HENRY S WICKER JR. M.D.

Table of content: DR. HENRY S WICKER JR. M.D. (NPI 1548233703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548233703 NPI number — DR. HENRY S WICKER JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKER
Provider First Name:
HENRY
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1548233703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22402-1460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-786-2100
Provider Business Mailing Address Fax Number:
540-786-0677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4701 SPOTSYLVANIA PKWY
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22407-9435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-834-5450
Provider Business Practice Location Address Fax Number:
540-834-5451
Provider Enumeration Date:
02/08/2006

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: 208600000X , with the licence number:  0101044445 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 137724 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 007306172 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4235093 . This is a "AETNA NON HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 425273 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0898260 . This is a "AETNA HMO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C02375 . This is a "MEDICARE GROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: CA9037 . This is a "MCR RAILROAD GROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 0101044445 . This is a "LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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