Basic Information
| Provider Information | |||||||||
| NPI: | 1174621114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR. DALE WICKSTROM-HILL PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 198096 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303848096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 8666652702 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528678898 | ||||||||
| FaxNumber: | 3527326282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 04/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | WICKSTROM-HILL | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3528678898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | OS0006374 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 050066689 | 01 | FL | RAILROAD MEDICARE | OTHER | 80933 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 003632900 | 05 | FL | MEDICAID | 269252000 | 05 | FL | MEDICAID |