Basic Information
Provider Information | |||||||||
NPI: | 1033506274 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LICK | ||||||||
FirstName: | WILLIAM | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LICK | ||||||||
OtherFirstName: | CORKY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 4300 MARKETPOINTE DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 554355435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528359880 | ||||||||
FaxNumber: | 9528571554 | ||||||||
Practice Location | |||||||||
Address1: | 550 PEACHTREE ST NE | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30308 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4046863845 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2015 | ||||||||
LastUpdateDate: | 10/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 61361 | CT | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 82768 | GA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | 70308 | MN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.