Healthcare Provider Details

I. General information

NPI: 1043288616
Provider Name (Legal Business Name): EDWARD E KICE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E 19TH ST
THE DALLES OR
97058-3317
US

IV. Provider business mailing address

PO BOX 1044
THE DALLES OR
97058-9044
US

V. Phone/Fax

Practice location:
  • Phone: 541-298-7936
  • Fax: 541-296-7619
Mailing address:
  • Phone: 541-298-7936
  • Fax: 541-296-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD18439
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: