MEDICARE: DR. MAURICE MCCALL VICK JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician	009957	LA

General Provider Information

NPI Number	:	1871726000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAURICE MCCALL VICK JR. MD

Provider Business Mailing Address
First Line	:	5225 ODONOVAN
Second Line	:	STE 102
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-7202
Country	:	US
Telephone Number	:	225-767-2686
Fax Number	:	225-767-2687

Provider Business Practice Location Address
First Line	:	5225 ODONOVAN
Second Line	:	STE 102
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-7202
Country	:	US
Telephone Number	:	225-767-2686
Fax Number	:	225-767-2687

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2009
Last Update Date	:	09/04/2009

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