MEDICARE: DR. GERRY-LYNN WICHMANN 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	390200000X	Student in an Organized Health Care Education/Training Program
2	2084P0800X	Psychiatry Physician	48276	KY

General Provider Information

NPI Number	:	1134418494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERRY-LYNN WICHMANN M.D.

Provider Business Mailing Address
First Line	:	PO BOX 6548
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40206-0548
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 S PRESTON ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-1702
Country	:	US
Telephone Number	:	502-999-9999
Fax Number	:

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

Provider Enumeration Date	:	04/06/2011
Last Update Date	:	08/06/2019

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