MEDICARE: MR. BRIAN KYLE WICKER PT

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	225100000X	Physical Therapist	PT2995	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437185188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN KYLE WICKER PT

Provider Business Mailing Address
First Line	:	PO BOX 1016
Second Line	:
City	:	OXFORD
State	:	MS
Zip	:	38655-5221
Country	:	US
Telephone Number	:	662-238-2800
Fax Number	:	662-238-2808

Provider Business Practice Location Address
First Line	:	2205 JEFFERSON DAVIS DR
Second Line	:
City	:	OXFORD
State	:	MS
Zip	:	38655-5221
Country	:	US
Telephone Number	:	662-238-2800
Fax Number	:	662-238-2808

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

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	01/27/2011

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