Provider Demographics
NPI:1629121223
Name:SUSAN WICKE, MD, PC
Entity Type:Organization
Organization Name:SUSAN WICKE, MD, PC
Other - Org Name:SUSAN WICKE, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:HOLLY
Authorized Official - Last Name:WICKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-493-3932
Mailing Address - Street 1:112 SWIFT AVENUE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705
Mailing Address - Country:US
Mailing Address - Phone:919-493-3932
Mailing Address - Fax:919-493-3932
Practice Address - Street 1:112 SWIFT AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4800
Practice Address - Country:US
Practice Address - Phone:919-493-3932
Practice Address - Fax:919-493-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36618261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130949OtherCIGNA BEHAVIORAL HEALTH
NC87341OtherBCBSNC PROVIDER NUMBER
NC2188551AMedicare ID - Type Unspecified
NC130949OtherCIGNA BEHAVIORAL HEALTH