Provider Demographics
NPI:1669451407
Name:HICKEY, EDITH S (MD)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:S
Last Name:HICKEY
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:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:225 PHYSICIANS PARK STE 400
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3923
Practice Address - Country:US
Practice Address - Phone:573-727-5500
Practice Address - Fax:573-727-5599
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1414006001Medicaid
080147243OtherTRAVELERS MEDICARE
MO204668008Medicaid
F71484Medicare UPIN
000094506Medicare ID - Type Unspecified