Provider Demographics
NPI:1114985272
Name:HICKEY, HOMER DAVID JR (MD)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:DAVID
Last Name:HICKEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1325 WOLF PARK DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1742
Mailing Address - Country:US
Mailing Address - Phone:901-252-3411
Mailing Address - Fax:901-384-6422
Practice Address - Street 1:1325 WOLF PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1742
Practice Address - Country:US
Practice Address - Phone:901-252-3400
Practice Address - Fax:901-682-0047
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN05554208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2005835OtherBLUE CROSS TN
TN3153875Medicaid
4664755OtherAETNA
02110025700OtherQUAL CHOICE
770396OtherFIRST HEALTH
12939795OtherPHCS
3153875OtherALL OTHER TENNCARE PLANS
6107353OtherCIGNA
12939795OtherHEALTH ASSURANCE EPA
2005835OtherTENNCARE SELECT
211159OtherSOUTHERN HEALTH SERVICES
381844OtherHEALTH LINK
92802OtherBLUE CROSS AR
92802OtherBLUE CROSS AR
381844OtherHEALTH LINK