Basic Information
| Provider Information | |||||||||
| NPI: | 1972519213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICK | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 PETERSON PARKWAY | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | NEW LONDON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3203542222 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 PETERSON PARKWAY | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | NEW LONDON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3203542222 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 04/12/2011 | ||||||||
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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 | 207Q00000X | 48788 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01-25488 | 01 | MN | MEDICA | OTHER | 165H7HO | 01 | MN | BCBSMN | OTHER | P00442141 | 01 | RR MEDICARE PTAN | OTHER | 985172000 | 05 | MN | MEDICAID |