Healthcare Provider Details

I. General information

NPI: 1275082406
Provider Name (Legal Business Name): TIM FICK AAS-HIS, BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5157 LEMAY FERRY RD
SAINT LOUIS MO
63129-1533
US

IV. Provider business mailing address

5157 LEMAY FERRY RD
SAINT LOUIS MO
63129-1533
US

V. Phone/Fax

Practice location:
  • Phone: 314-487-5550
  • Fax: 314-487-5554
Mailing address:
  • Phone: 314-487-5550
  • Fax: 314-487-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2015015579
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3239
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: