Healthcare Provider Details

I. General information

NPI: 1184354169
Provider Name (Legal Business Name): KAMAAL ABDUL-RAHEEM HICKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEMORIAL DR STE 220
ALTON IL
62002-6723
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-474-1723
  • Fax: 618-433-6299
Mailing address:
  • Phone: 618-474-1723
  • Fax: 618-433-6299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036173538
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.173538
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: