Provider Demographics
NPI:1629249560
Name:MITCHELL WICKER., JR., M.D., P.S.C.
Entity Type:Organization
Organization Name:MITCHELL WICKER., JR., M.D., P.S.C.
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
Mailing Address - Country:US
Mailing Address - Phone:606-439-1316
Mailing Address - Fax:606-439-4224
Practice Address - Street 1:271 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701
Practice Address - Country:US
Practice Address - Phone:606-439-1316
Practice Address - Fax:606-439-4224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-08-11
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
KY65915910Medicaid