Provider Demographics
NPI:1467480327
Name:HICKS, KIMBERLY GRIFFIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:GRIFFIN
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 1:460 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5782
Mailing Address - Country:US
Mailing Address - Phone:865-271-9536
Mailing Address - Fax:865-986-0212
Practice Address - Street 1:460 MEDICAL PARK DR
Practice Address - Street 2:SUITE 108
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5782
Practice Address - Country:US
Practice Address - Phone:865-271-9536
Practice Address - Fax:865-986-0212
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD34033208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516025Medicaid
KY64054729Medicaid
TN3496552Medicaid
TN4034474OtherBLUE CROSS