Provider Demographics
NPI:1174621114
Name:DR. DALE WICKSTROM-HILL PA
Entity type:Organization
Organization Name:DR. DALE WICKSTROM-HILL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKSTROM-HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-867-8898
Mailing Address - Street 1:PO BOX 198096
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8096
Mailing Address - Country:US
Mailing Address - Phone:352-867-8898
Mailing Address - Fax:866-665-2702
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:352-867-8898
Practice Address - Fax:352-732-6282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006374207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050066689OtherRAILROAD MEDICARE
FL80933OtherBLUE CROSS BLUE SHIELD
FL003632900Medicaid
FL269252000Medicaid
FL269252000Medicaid