Provider Demographics
NPI:1396819462
Name:GREGORY D HICKS M.D. P.A-PLASTIC & RECONSRUCTIVE SURGERY
Entity Type:Organization
Organization Name:GREGORY D HICKS M.D. P.A-PLASTIC & RECONSRUCTIVE SURGERY
Other - Org Name:PROFESSIONAL PLASTIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIELES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-925-3633
Mailing Address - Street 1:3801 BEE RIDGE ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233
Mailing Address - Country:US
Mailing Address - Phone:941-925-3633
Mailing Address - Fax:941-925-1435
Practice Address - Street 1:3801 BEE RIDGE ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233
Practice Address - Country:US
Practice Address - Phone:941-925-3633
Practice Address - Fax:941-925-1435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42730208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0634409-00Medicaid
10121Medicare ID - Type Unspecified
FL0634409-00Medicaid