Basic Information
| Provider Information | |||||||||
| NPI: | 1922058015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICKERY | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 MEDICAL CENTER DR | ||||||||
| Address2: | C/O ACRMC OUTPATIENT CLINIC | ||||||||
| City: | SEAMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456798002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373863420 | ||||||||
| FaxNumber: | 9373863439 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 MEDICAL CENTER DR | ||||||||
| Address2: | C/O ACRMC OUTPATIENT CLINIC | ||||||||
| City: | SEAMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456798002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373863420 | ||||||||
| FaxNumber: | 9373863439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/31/2010 | ||||||||
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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 | 2084N0400X | 35-04-3357 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0460826 | 05 | OH | MEDICAID |