Provider Demographics
NPI:1982875050
Name:DOUGLAS E. VICK, DO M. TAMARIN VICK, DO
Entity Type:Organization
Organization Name:DOUGLAS E. VICK, DO M. TAMARIN VICK, DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:TAMARIN
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:859-873-8044
Mailing Address - Street 1:208 CROSSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1468
Mailing Address - Country:US
Mailing Address - Phone:859-873-8044
Mailing Address - Fax:859-873-8045
Practice Address - Street 1:208 CROSSFIELD DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1468
Practice Address - Country:US
Practice Address - Phone:859-873-8044
Practice Address - Fax:859-873-8045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02382204D00000X, 207Q00000X
KY02383208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F78724Medicare UPIN
2894Medicare PIN
A67747Medicare UPIN