Basic Information
| Provider Information | |||||||||
| NPI: | 1144484361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKMAN | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8935 N MERIDIAN ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175744747 | ||||||||
| FaxNumber: | 3175744737 | ||||||||
| Practice Location | |||||||||
| Address1: | 8330 NAAB RD | ||||||||
| Address2: | SUITE 234 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178750084 | ||||||||
| FaxNumber: | 3178765580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2008 | ||||||||
| LastUpdateDate: | 10/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 01072427A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 201166110 | 05 | IN | MEDICAID |