NPIMap

Individual provider Active NPI

Jason W. Wickersham, M.D.

  • Family Medicine Physician
  • Parkston, SD
National Provider Identifier
1073594172
Registry record updated Aug 9, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5450 Issued in SD
Practice address
401 W Glynn Dr
Parkston, SD 57366-9605
Phone
(605) 928-3311
Fax
(605) 928-7368
NPI assigned
Nov 7, 2005
Last updated
Aug 9, 2012By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 9, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 5450 SD Primary

Addresses

Primary practice location

401 W Glynn Dr
Parkston, SD 57366-9605

Mailing address

401 W Glynn Dr
Parkston, SD 57366-9605
Phone (605) 928-3311

Other identifiers 4

IdentifierTypeStateIssuer
5611620MedicaidSD
5340340MedicaidSD
4995341OtherSDWELLMARK
5340070MedicaidSD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040504000306 SD Practitioner - Family PracticePractitioner - Emergency Medicine 7810889763 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family PracticeAlso: Emergency Medicine
Education
Sanford School of Medicine of University of South Dakota, 2001
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
St Benedict Health CenterGroup PAC ID 4880507672, shared by 5 NPIs, 13 clinicians

Practice addresses (Care Compare)

401 W Glynn Dr
Parkston, SD 57366-9605
Phone (605) 928-7961

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Colonoscopy1-10
Upper gastrointestinal (GI) endoscopy for acid reflux1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
St. Benedict Health Center Family Medicine CurrentSince Jul 1, 2004 Accepting new patients
St Benedict Health Center Family Medicine CurrentSince Jul 1, 2004 Accepting new patients
St Benedict Health Center Current Accepting new patients
Alegent Creighton Clinic Family Medicine Past Accepting new patients
Alegent Creighton Clinic Family Medicine Past Accepting new patients

Locations

401 W Glynn Dr
Parkston, SD 57366
Phone (605) 928-3311

Interoperability endpoints

  • Direct secure messaging: jason.wickersham@avera.sdhealthlink.net

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 29

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 29

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1131321600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1344470400000",
    "number": "1073594172",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "401 W GLYNN DR",
            "city": "PARKSTON",
            "state": "SD",
            "postal_code": "573669605",
            "telephone_number": "605-928-3311",
            "fax_number": "605-928-7368"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "401 W GLYNN DR",
            "city": "PARKSTON",
            "state": "SD",
            "postal_code": "573669605",
            "telephone_number": "605-928-3311",
            "fax_number": "605-928-7368"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WICKERSHAM",
        "first_name": "JASON",
        "middle_name": "W.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-11-07",
        "last_updated": "2012-08-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SD",
            "license": "5450",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5611620",
            "state": "SD"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5340340",
            "state": "SD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WELLMARK",
            "identifier": "4995341",
            "state": "SD"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5340070",
            "state": "SD"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Parkston, SD

Sources for this page

Verify at the official NPI Registry.