Healthcare Provider Details

I. General information

NPI: 1790926434
Provider Name (Legal Business Name): EMERSON M. WICKWIRE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 LINDEN AVE
BALTIMORE MD
21201-4606
US

IV. Provider business mailing address

PO BOX 64442
BALTIMORE MD
21264-4442
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-8141
  • Fax: 410-328-0177
Mailing address:
  • Phone: 410-225-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04597
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number04597
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: