Healthcare Provider Details

I. General information

NPI: 1336333913
Provider Name (Legal Business Name): COLLEEN HICKEY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E ONTARIO ST SUITE 200-300
CHICAGO IL
60611-3468
US

IV. Provider business mailing address

211 E ONTARIO ST SUITE 200-300
CHICAGO IL
60611-3468
US

V. Phone/Fax

Practice location:
  • Phone: 312-694-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125049121
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: