MEDICARE: MICHAEL L VICK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	044656	GA

General Provider Information

NPI Number	:	1073503165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL L VICK

Provider Business Mailing Address
First Line	:	504 W MEMORIAL DR
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-4119
Country	:	US
Telephone Number	:	770-505-7190
Fax Number	:	770-793-7413

Provider Business Practice Location Address
First Line	:	504 W MEMORIAL DR
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-4119
Country	:	US
Telephone Number	:	770-505-7190
Fax Number	:	770-793-7413

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	07/08/2007

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