=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093709750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON R BICKEL DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2005
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 BROADWAY ST
-----------------------------------------------------
City | VINCENNES
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47591-1228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-882-3312
-----------------------------------------------------
Fax | 812-882-6181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1160 E SAINT CLAIR ST
-----------------------------------------------------
City | VINCENNES
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47591-4853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-885-3325
-----------------------------------------------------
Fax | 812-885-8499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 599
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 07001040A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 07001040A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------