Provider Demographics
NPI:1245541622
Name:WICKMAN FAMILY MEDICAL CARE
Entity type:Organization
Organization Name:WICKMAN FAMILY MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. M.P.H.
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-377-3001
Mailing Address - Street 1:8485 US HIGHWAY 64 STE 101
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4102
Mailing Address - Country:US
Mailing Address - Phone:901-377-3001
Mailing Address - Fax:901-377-3130
Practice Address - Street 1:8485 US HIGHWAY 64 STE 101
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133-4102
Practice Address - Country:US
Practice Address - Phone:901-377-3001
Practice Address - Fax:901-377-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty