Provider Demographics
NPI:1790926434
Name:WICKWIRE, EMERSON M (PHD)
Entity Type:Individual
Prefix:
First Name:EMERSON
Middle Name:M
Last Name:WICKWIRE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-225-8000
Mailing Address - Fax:
Practice Address - Street 1:827 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4606
Practice Address - Country:US
Practice Address - Phone:410-328-8141
Practice Address - Fax:410-328-0177
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04597207RS0012X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS062-0565OtherCAREFIRST BC/BS
MD418389400Medicaid
MD163433ZCEAMedicare PIN