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General NPI Number Information
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NPI Number | 1629121223
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Entity Type | Organization
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Legal Business Name | SUSAN WICKE, MD, PC
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 08/23/2007
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Provider Practice Location Address
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Address Line | 112 SWIFT AVE
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City | DURHAM
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State | NC
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Zip | 27705-4800
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Country | US
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Telephone | 919-493-3932
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Fax | 919-493-3932
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Provider Business Mailing Address
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Address Line | 112 SWIFT AVENUE
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City | DURHAM
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State | NC
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Zip | 27705
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Country | US
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Telephone | 919-493-3932
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Fax | 919-493-3932
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Authorized Official
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Title or Position | PSYCHIATRIST
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Name | DR. SUSAN HOLLY WICKE
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Credential | M.D.
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Telephone | 919-493-3932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 36618
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License Number State | NC
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