Healthcare Provider Details

I. General information

NPI: 1972669265
Provider Name (Legal Business Name): RYAN MATTHEW HICKEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016
US

IV. Provider business mailing address

1 IRVING PL APT U16A
NEW YORK NY
10003-9727
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5230
  • Fax:
Mailing address:
  • Phone: 312-926-4068
  • Fax: 312-695-5645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036122319
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: