Provider Demographics
NPI:1992732994
Name:WICKER, KENNETH D (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:WICKER
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:PO BOX 634706
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2018 W CLINCH AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2301
Practice Address - Country:US
Practice Address - Phone:865-541-8000
Practice Address - Fax:865-539-8008
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD18702207P00000X, 208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64928021Medicaid
TN3082433Medicaid
TN3082430Medicaid
TN3055615OtherBLUE CROSS
TN3082434Medicaid
TN4152062OtherBLUE CROSS
TN3112589OtherBLUE CROSS
TN3112589OtherBLUE CROSS
TN3082430Medicaid
TN3082433Medicare PIN