Provider Demographics
NPI:1417130766
Name:NIKOLA BICAK DBA JACKSON FOOT & ANKLE CLINIC
Entity Type:Organization
Organization Name:NIKOLA BICAK DBA JACKSON FOOT & ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BICAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-372-3788
Mailing Address - Street 1:PO BOX 796
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25271-0796
Mailing Address - Country:US
Mailing Address - Phone:304-372-3788
Mailing Address - Fax:304-372-1513
Practice Address - Street 1:844 ROUTE 62 SOUTH
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-8408
Practice Address - Country:US
Practice Address - Phone:304-372-3788
Practice Address - Fax:304-372-1513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV307213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0099957000Medicaid
WV4344300001Medicare NSC
WV0791281Medicare PIN