Provider Demographics
NPI:1760490064
Name:GARY WIKERT MD PLLC
Entity Type:Organization
Organization Name:GARY WIKERT MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GALE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WIKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-707-5313
Mailing Address - Street 1:29 TAYLOR AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4527
Mailing Address - Country:US
Mailing Address - Phone:931-707-5313
Mailing Address - Fax:
Practice Address - Street 1:29 TAYLOR AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4527
Practice Address - Country:US
Practice Address - Phone:931-707-5313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND31365OtherUPIN
TN3735040Medicaid
TNPOO906801OtherRR MCR
TN3735040Medicare PIN