Healthcare Provider Details

I. General information

NPI: 1982600060
Provider Name (Legal Business Name): RANDALL D HICKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 15TH ST FL 2
MERIDIAN MS
39301-4130
US

IV. Provider business mailing address

PO BOX 749215
ATLANTA GA
30374-9215
US

V. Phone/Fax

Practice location:
  • Phone: 601-553-2000
  • Fax: 601-483-8869
Mailing address:
  • Phone: 901-226-3186
  • Fax: 901-226-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number10697
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: