Basic Information
| Provider Information | |||||||||
| NPI: | 1548233703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKER | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1460 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224021460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407862100 | ||||||||
| FaxNumber: | 5407860677 | ||||||||
| Practice Location | |||||||||
| Address1: | 4701 SPOTSYLVANIA PKWY | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224079435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408345450 | ||||||||
| FaxNumber: | 5408345451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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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 | 208600000X | 0101044445 | VA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 137724 | 01 | VA | ANTHEM | OTHER | 007306172 | 05 | VA | MEDICAID | 4235093 | 01 | VA | AETNA NON HMO | OTHER | 425273 | 01 | VA | MAMSI | OTHER | 0898260 | 01 | VA | AETNA HMO | OTHER | C02375 | 01 | VA | MEDICARE GROUP | OTHER | CA9037 | 01 | VA | MCR RAILROAD GROUP | OTHER | 0101044445 | 01 | VA | LICENSE | OTHER |