Healthcare Provider Details

I. General information

NPI: 1104802388
Provider Name (Legal Business Name): JOHN TRIMMER HICKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 BYPASS 225 S
GREENWOOD SC
29646-8025
US

IV. Provider business mailing address

PO BOX 427
GREENWOOD SC
29648-0427
US

V. Phone/Fax

Practice location:
  • Phone: 864-953-8002
  • Fax: 864-953-9690
Mailing address:
  • Phone: 864-953-8002
  • Fax: 864-953-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number15159
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: