MEDICARE: DR. MARY VAN SICKLE 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	207V00000X	Obstetrics & Gynecology Physician	H5211	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0063PA	OTHER	TX	BLUE CROSS ID

General Provider Information

NPI Number	:	1376545616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY VAN SICKLE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 6880
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87502-6880
Country	:	US
Telephone Number	:	505-395-2288
Fax Number	:	505-983-8135

Provider Business Practice Location Address
First Line	:	7777 SOUTHWEST FWY
Second Line	:	STE 616
City	:	HOUSTON
State	:	TX
Zip	:	77074-1802
Country	:	US
Telephone Number	:	713-773-3983
Fax Number	:	713-271-4076

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	06/28/2017

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