Otto William Wickstrom III, M.D.

Primary specialty

Orthopaedic Hand Surgery PhysicianTaxonomy code 207XS0106X

License

MD61074238 Issued in WA

Practice address

583 S Clarizz Blvd
Bloomington, IN 47401-5515

Phone

(812) 333-2663

Fax

(812) 349-9206

NPI assigned

Mar 25, 2008

Sex

Male

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in IN, WA2 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 2

Specialty

Hand SurgeryAlso: Orthopedic Surgery

Education

Other, 2003

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Iu Health Medical Group LLCGroup PAC ID 9638617913, 4,382 clinicians

Indiana University Health Southern Indiana Physicians LLCGroup PAC ID 6204748197, 474 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Indiana University Health Bloomington Hospital Hospital, Bloomington, IN, CCN 150051
• Indiana University Health Hospital, Indianapolis, IN, CCN 150056

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kjohnson1@yourcarecommunity.org
• Direct secure messaging: owickstr@direct.iuhealth.org
• Direct secure messaging: owickstrom1363585@wm.providencedirect.org

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

• Iu Health Medical Group, LLC

  • General Practice Physician
  • Indianapolis, IN
  • NPI 1326893777
  Medicare reassignment Care Compare group NPD
• Indiana University Health Southern Indiana Physicians, LLC

  • Multi-Specialty Clinic/Center
  • Bloomington, IN
  • NPI 1013953983
  Medicare reassignment Care Compare group
• Providence Health & Services Washington

  • Pulmonary Disease Physician
  • Spokane, WA
  • NPI 1194099390
  Medicare reassignment

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

• Indiana University Health Bloomington Inc

  • General Acute Care Hospital
  • Bloomington, IN
  • NPI 1205860335
  Care Compare affiliation
• Indiana University Health Inc

  • General Acute Care Hospital
  • Indianapolis, IN
  • NPI 1144266024
  Care Compare affiliation

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

{
    "created_epoch": "1206403200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1619654400000",
    "number": "1487826939",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "583 S CLARIZZ BLVD",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474015515"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "583 S CLARIZZ BLVD",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474015515",
            "telephone_number": "812-333-2663",
            "fax_number": "812-349-9206"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "16528 E Desmet Ct",
            "address_purpose": "LOCATION",
            "city": "Spokane Valley",
            "state": "WA",
            "postal_code": "992163522",
            "country_code": "US",
            "telephone_number": "509-944-8920",
            "fax_number": "509-227-7070",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WICKSTROM",
        "first_name": "OTTO",
        "middle_name": "WILLIAM",
        "name_prefix": "Dr.",
        "name_suffix": "III",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-03-25",
        "last_updated": "2021-04-29",
        "certification_date": "2021-04-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207X00000X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery",
            "state": "WA",
            "license": "MD61074238",
            "primary": false
        },
        {
            "code": "207XS0106X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery, Hand Surgery",
            "state": "WA",
            "license": "MD61074238",
            "primary": true
        },
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "IN",
            "license": "01065381A",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200931500",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "owickstrom1363585@wm.providencedirect.org",
            "affiliation": "N",
            "address_1": "820 S McClellan St Ste 300B",
            "city": "Spokane",
            "state": "WA",
            "country_code": "US",
            "postal_code": "992042457",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Todd Mitchell Whitlock, D.D.S.
• Kelly Whitney-Babcock, A.T.C., L.A.T.
• Kegahn Whyte, RBT
• Hayley Rose Wible, D.O.
• Jonathan Wicks, ATC, LAT, M.ED
• Theresa Wiegand-Swihart, M.S.,OTR/CHT
• Wig Wam Boutique LLC
• Lindsay Wiggs
• Marjorie Ellen Wiles, LCSW
• Lori Ann Wiley, P.T.

• Orthopaedic Hand Surgery Physician in Bloomington, IN
• Providers in Bloomington, IN by specialty
• Orthopaedic Hand Surgery Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.