Basic Information
| Provider Information | |||||||||
| NPI: | 1992887855 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VICKERY FAMILY MEDICINE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 YORKSHIRE ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288037783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282741600 | ||||||||
| FaxNumber: | 8282741603 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 YORKSHIRE ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288032760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282741600 | ||||||||
| FaxNumber: | 8282741603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | VICKERY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | AUGUSTUS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8282741600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200201416 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5908828 | 05 | NC | MEDICAID |