=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104802388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN TRIMMER HICKS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2005
-----------------------------------------------------
Last Update Date | 04/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 917 BYPASS 225 S
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-8025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-953-8002
-----------------------------------------------------
Fax | 864-953-9690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 427
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29648-0427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-953-8002
-----------------------------------------------------
Fax | 864-953-9690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 15159
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------