Provider Demographics
NPI:1235392408
Name:WINNIE CLAIRE HICKS
Entity Type:Organization
Organization Name:WINNIE CLAIRE HICKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:WINNIE
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-588-2511
Mailing Address - Street 1:162 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0101
Mailing Address - Country:US
Mailing Address - Phone:912-588-2511
Mailing Address - Fax:912-588-2518
Practice Address - Street 1:162 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0101
Practice Address - Country:US
Practice Address - Phone:912-588-2511
Practice Address - Fax:912-588-2518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA238379OtherBLUE CROSS/BLUE SHIELD
GAGRP2943OtherMEDICARE GROUP #
GA252867447OtherINSURANCES
GA000369597AMedicaid
GA238379OtherBLUE CROSS/BLUE SHIELD
E00387Medicare UPIN