Healthcare Provider Details

I. General information

NPI: 1013053172
Provider Name (Legal Business Name): JONATHAN JOSEF SKONICKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 LOOP RD TUSCALOOSA VA MEDICAL CENTER,
TUSCALOOSA AL
35404-5015
US

IV. Provider business mailing address

3701 LOOP RD TUSCALOOSA VA MEDICAL CENTER,
TUSCALOOSA AL
35404-5015
US

V. Phone/Fax

Practice location:
  • Phone: 205-554-2000
  • Fax:
Mailing address:
  • Phone: 205-554-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24572
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number30198
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: