Provider Demographics
NPI:1518927631
Name:HICK, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 CESAR CHAVEZ ST
Mailing Address - Street 2:
Mailing Address - City:W. ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2226
Mailing Address - Country:US
Mailing Address - Phone:651-222-1816
Mailing Address - Fax:651-222-1305
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:W. ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-222-1816
Practice Address - Fax:651-222-1305
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP16392OtherHEALTH PARTNERS
MN122288100Medicaid
MN111858OtherUCARE
MN32T71HIOtherBCBS
MN1200583OtherMEDICA
MN111858OtherUCARE