Basic Information
| Provider Information | |||||||||
| NPI: | 1093709750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BICKEL | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1160 E SAINT CLAIR ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475914853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128853325 | ||||||||
| FaxNumber: | 8128858499 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128823312 | ||||||||
| FaxNumber: | 8128826181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 599 | TN | N | Other Service Providers | Specialist | 213ES0103X | 07001040A | IN | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | 07001040A | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 000000542568 | 01 | IN | ANTHEM | OTHER | 000000542574 | 01 | IL | ANTHEM | OTHER | 200879590A | 05 | IN | MEDICAID |