MEDICARE: GREG MICK D.O., PLLC

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	208D00000X	General Practice Physician	02503	KY

General Provider Information

NPI Number	:	1215320056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREG MICK D.O., PLLC

Provider Business Mailing Address
First Line	:	2375 PROFESSIONAL HEIGHTS DR
Second Line	:	SUITE 240
City	:	LEXINGTON
State	:	KY
Zip	:	40503-3040
Country	:	US
Telephone Number	:	859-523-8996
Fax Number	:	859-523-9370

Provider Business Practice Location Address
First Line	:	2375 PROFESSIONAL HEIGHTS DR
Second Line	:	SUITE 240
City	:	LEXINGTON
State	:	KY
Zip	:	40503-3040
Country	:	US
Telephone Number	:	859-523-8996
Fax Number	:	859-523-9370

Authorized Official
Title or Position	:	MANAGER
Name	:	JOHN DANIELS
Credential	:
Telephone Number	:	859-523-8996

Provider Enumeration Date	:	03/17/2015
Last Update Date	:	03/17/2015

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