MEDICARE: WYRICK DERMATOLOGY ASSOCIATION

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	261Q00000X	Clinic/Center

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619977295
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYRICK DERMATOLOGY ASSOCIATION

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	:	PRESIDENT
Name	:	SCOTT W WYRICK
Credential	:	M.D.
Telephone Number	:	903-792-3787

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	04/09/2013

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