Provider Demographics
NPI:1043320427
Name:HICKS, FRED G (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:G
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11477 OLDE CABIN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7130
Mailing Address - Country:US
Mailing Address - Phone:314-567-5000
Mailing Address - Fax:314-567-3110
Practice Address - Street 1:11477 OLDE CABIN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7130
Practice Address - Country:US
Practice Address - Phone:314-567-5000
Practice Address - Fax:314-567-3110
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7D142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100730OtherHEALTHLINK
MO17058OtherBLUE CROSS BLUE SHIELD
MO1581541OtherUNITED HEALTHCARE
MO202118311Medicaid
MO260006282OtherRR MEDICARE
MO000002960Medicare ID - Type Unspecified
MO100730OtherHEALTHLINK