Provider Demographics
NPI:1205851383
Name:VICK, TARA (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:VICK
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 N STATE OF FRANKLIN RD FL 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6056
Practice Address - Country:US
Practice Address - Phone:423-439-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101293207V00000X
TN62336207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ065587Medicaid
SCN01078Medicaid
NC130A5OtherBCBS NC
NC89130A5Medicaid
NC160054756Medicare PIN
ND2293666AMedicare PIN
NC130A5OtherBCBS NC
NC2293666AMedicare PIN