Healthcare Provider Details

I. General information

NPI: 1124193313
Provider Name (Legal Business Name): VICKERY NEURODIAGNOSTICS GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 JENNIFER CT SUITEB
CARLISLE PA
17015-7791
US

IV. Provider business mailing address

3 JENNIFER CT SUITEB
CARLISLE PA
17015-7791
US

V. Phone/Fax

Practice location:
  • Phone: 717-245-2226
  • Fax: 717-245-0316
Mailing address:
  • Phone: 717-245-2226
  • Fax: 717-245-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD031004E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0014792300003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: DR. JON L VICKERY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 717-245-2226