Healthcare Provider Details

I. General information

NPI: 1528296324
Provider Name (Legal Business Name): CHRISTINA KIM AHN HICKEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL STE C
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8116
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6173
  • Fax: 314-454-2412
Mailing address:
  • Phone: 314-454-6173
  • Fax: 314-454-2412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2013018916
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number2013018916
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: