MEDICARE: SCOTT W WYRICK M.D.

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	207Q00000X	Family Medicine Physician	J2424	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	070016709	OTHER	TX	MEDICARE RAILROAD
5	8312J1	OTHER	TX	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80451Y	OTHER	TX	BLUE CROSS
2	T0120358	OTHER	TX	CONTROLLED SUBSTANCES REG
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	99096	OTHER	AR	BLUE CROSS
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114920972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT W WYRICK M.D.

Provider Business Mailing Address
First Line	:	3333 POTOMAC AVE
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-3513
Country	:	US
Telephone Number	:	903-792-3787
Fax Number	:	903-792-0446

Provider Business Practice Location Address
First Line	:	3333 POTOMAC AVE
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-3513
Country	:	US
Telephone Number	:	903-792-3787
Fax Number	:	903-792-0446

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	03/07/2023

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1285908335 — B PEDIATRICS PLLC
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Directions to “ SCOTT W WYRICK M.D.” Practice Location

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