=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538226220
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERYL B VICKERY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 07/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 203 OAKSIDE LN STE C
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-6407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-410-7911
-----------------------------------------------------
Fax | 770-604-1929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5554
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-0290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-410-7911
-----------------------------------------------------
Fax | 770-604-1929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 026446
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------