Provider Demographics
NPI:1437121134
Name:WICHMAN, NEVILLE R (MD)
Entity type:Individual
Prefix:
First Name:NEVILLE
Middle Name:R
Last Name:WICHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-815-4775
Mailing Address - Fax:601-984-6451
Practice Address - Street 1:2500 NORTH STATE ST.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-2538
Practice Address - Fax:601-815-1854
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000218452085R0202X
FLME888852085R0202X
MS139662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG7781OtherRAILROAD - GROUP
CD5130OtherGROUP #
P00621714OtherRAILROAD MEDICARE
MS512G700003OtherMS MEDICARE - GROUP
P00462360OtherRAILROAD MEDICARE
MS25025853Medicaid
051526630Medicare PIN
000058867Medicare PIN
P00621714OtherRAILROAD MEDICARE
051504364Medicare PIN
MS512G700003OtherMS MEDICARE - GROUP
DG7781OtherRAILROAD - GROUP
MS5121300039Medicare PIN
051526551Medicare PIN