Healthcare Provider Details

I. General information

NPI: 1700945474
Provider Name (Legal Business Name): ROBERT C HICKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 N SPRUCE ST
OGALLALA NE
69153-2465
US

IV. Provider business mailing address

826 W 27TH AVE
SPOKANE WA
99203-1838
US

V. Phone/Fax

Practice location:
  • Phone: 308-284-3645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00043363
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-5163
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberND-11439-A
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: