Provider Demographics
NPI:1801004197
Name:KICK, PHILLIP STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:STEPHEN
Last Name:KICK
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 1:5881 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-2910
Mailing Address - Country:US
Mailing Address - Phone:970-353-1551
Mailing Address - Fax:970-350-2478
Practice Address - Street 1:5881 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2910
Practice Address - Country:US
Practice Address - Phone:970-353-1551
Practice Address - Fax:970-350-2478
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA231126208800000X
CODR.0057971208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000143001Medicaid
CO9000143001Medicaid