Basic Information
| Provider Information | |||||||||
| NPI: | 1740360734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WICAL | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 UNIVERSITY AVE E | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513252325 | ||||||||
| FaxNumber: | 6512291718 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 UNIVERSITY AVE E | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513252325 | ||||||||
| FaxNumber: | 6512291718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | 37563 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 637750500 | 05 | MN | MEDICAID |