Healthcare Provider Details

I. General information

NPI: 1205835717
Provider Name (Legal Business Name): SAMUEL HICKEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/16/2024
Certification Date: 11/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42440 PELICAN PROFESSIONAL PARK
HAMMOND LA
70403-2403
US

IV. Provider business mailing address

PO BOX 2668 BUSINESS CTR - INS CREDENTIALING
HAMMOND LA
70404-2403
US

V. Phone/Fax

Practice location:
  • Phone: 985-542-4950
  • Fax: 985-542-6089
Mailing address:
  • Phone: 985-230-1682
  • Fax: 985-230-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number024236
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: