Healthcare Provider Details

I. General information

NPI: 1518375567
Provider Name (Legal Business Name): MICHAEL W. VICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 GREATSTONE PT
LEXINGTON KY
40504
US

IV. Provider business mailing address

900 S LIMESTONE CTW 304
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-1000
  • Fax:
Mailing address:
  • Phone: 859-323-6561
  • Fax: 859-323-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberTP721
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTP721
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: