MEDICARE: HARLAN M HICKS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	200101216	NC

General Provider Information

NPI Number	:	1356333876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARLAN M HICKS M.D.

Provider Business Mailing Address
First Line	:	650 SIGNAL HILL DRIVE EXT
Second Line	:	PO BOX 1845
City	:	STATESVILLE
State	:	NC
Zip	:	28625-4353
Country	:	US
Telephone Number	:	704-873-4277
Fax Number	:	704-873-4511

Provider Business Practice Location Address
First Line	:	208 OLD MOCKSVILLE RD
Second Line	:
City	:	STATESVILLE
State	:	NC
Zip	:	28625-1930
Country	:	US
Telephone Number	:	704-838-8238
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	04/07/2010

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