Healthcare Provider Details

I. General information

NPI: 1316075997
Provider Name (Legal Business Name): ELIZABETH COLLENS WICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST BLALOCK 658
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64563
BALTIMORE MD
21264-4563
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-7323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA76824
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD67913
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: