Healthcare Provider Details

I. General information

NPI: 1063563864
Provider Name (Legal Business Name): PHILLIP HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

2003 EPICUREAN DR
CLINTON MO
64735-1887
US

V. Phone/Fax

Practice location:
  • Phone: 660-890-7103
  • Fax:
Mailing address:
  • Phone: 660-890-7103
  • Fax: 660-885-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number122530
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: