Provider Demographics
NPI:1023020989
Name:HICKOMBOTTOM, RONALD ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:ANTHONY
Last Name:HICKOMBOTTOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0018
Mailing Address - Country:US
Mailing Address - Phone:815-725-2121
Mailing Address - Fax:
Practice Address - Street 1:728 W JACKSON BLVD APT 306
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-5405
Practice Address - Country:US
Practice Address - Phone:312-622-6461
Practice Address - Fax:773-348-6781
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065509207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC44036Medicare UPIN