Provider Demographics
NPI:1417964214
Name:AMICK, ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:AMICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EXECUTIVE CENTER CT
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4487
Mailing Address - Country:US
Mailing Address - Phone:501-448-0060
Mailing Address - Fax:501-448-0066
Practice Address - Street 1:4 EXECUTIVE CENTER CT
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4487
Practice Address - Country:US
Practice Address - Phone:501-448-0060
Practice Address - Fax:501-448-0066
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-8191174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR55845OtherMEDICARE
ARP00411837OtherMEDICARE RAILROAD
AR55845OtherMEDICARE
ARP00411837OtherMEDICARE RAILROAD