Provider Demographics
NPI:1376501957
Name:HICKS, ROSELYN MARIE (MD)
Entity Type:Individual
Prefix:MISS
First Name:ROSELYN
Middle Name:MARIE
Last Name:HICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WESTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4320
Mailing Address - Country:US
Mailing Address - Phone:336-883-1393
Mailing Address - Fax:336-883-7517
Practice Address - Street 1:104 EAST NORTHWOOD STREET
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401
Practice Address - Country:US
Practice Address - Phone:336-373-0936
Practice Address - Fax:336-373-9844
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200915207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0200074OtherUNITED HEALTHCARE
NC132M1OtherBCBS
NC89132M1Medicaid
H74218Medicare UPIN
NC2004145Medicare ID - Type Unspecified