Provider Demographics
NPI:1093718116
Name:MITCHELL WICKER JR MD PSC
Entity Type:Organization
Organization Name:MITCHELL WICKER JR MD PSC
Other - Org Name:HAZARD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:606-439-1316
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-0719
Mailing Address - Country:US
Mailing Address - Phone:606-439-1316
Mailing Address - Fax:606-435-0752
Practice Address - Street 1:271 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1939
Practice Address - Country:US
Practice Address - Phone:606-439-1316
Practice Address - Fax:606-435-0752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31001035Medicaid
KYC74809Medicare UPIN
KY3714Medicare PIN