1033199898 NPI number — DR. TRACY HICKS M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033199898 NPI number — DR. TRACY HICKS M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

HICKS

Provider First Name:

TRACY

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1033199898

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/21/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

13700 ST FRANCIS BLVD

Provider Second Line Business Mailing Address:

SUITE 305

Provider Business Mailing Address City Name:

MIDLOTHIAN

Provider Business Mailing Address State Name:

VA

Provider Business Mailing Address Postal Code:

23114-3222

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

804-320-2483

Provider Business Mailing Address Fax Number:

804-419-1860

Provider First Line Business Practice Location Address:

13700 ST FRANCIS BLVD

Provider Second Line Business Practice Location Address:

SUITE 305

Provider Business Practice Location Address City Name:

MIDLOTHIAN

Provider Business Practice Location Address State Name:

VA

Provider Business Practice Location Address Postal Code:

23114-3222

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

804-320-2483

Provider Business Practice Location Address Fax Number:

804-419-1860

Provider Enumeration Date:

01/18/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207V00000X , with the licence number:  0101051067 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0000133671506 . This is a "UNITED" identifier . This identifiers is of the category "OTHER".
• Identifier: 11938 . This is a "CARENET" identifier . This identifiers is of the category "OTHER".
• Identifier: 94539 . This is a "SOUTHERN HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: C09633 . This is a "GROUP PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: 6201083 . This is a "VA PREMIER" identifier . This identifiers is of the category "OTHER".
• Identifier: 226116 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
• Identifier: 541941044102 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 160049264 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 330713 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
• Identifier: 69493 . This is a "OPTIMA HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: 006201083 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 69493 . This is a "SENTARA" identifier . This identifiers is of the category "OTHER".
• Identifier: 9276110 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
• Identifier: 0861892 . This is a "AETNA USHEALTH" identifier . This identifiers is of the category "OTHER".