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General NPI Number Information
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NPI Number | 1548548217
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Entity Type | Individual
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Provider Name | EDWARD GRANT VICK SR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/29/2011
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Last Update Date | 07/29/2011
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Provider Practice Location Address
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Address Line | 360 RED EAGLE CIR
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City | RIDGELAND
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State | MS
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Zip | 39157-9775
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Country | US
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Telephone | 601-856-1451
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Fax |
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Provider Business Mailing Address
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Address Line | 360 RED EAGLE CIR
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City | RIDGELAND
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State | MS
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Zip | 39157-9775
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Country | US
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Telephone | 601-856-1451
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 11522
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | MD8764
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License Number State | TN
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