Provider Demographics
NPI:1932141165
Name:HICKS, CRAIG A (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:A
Last Name:HICKS
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 1:2346 LANCECREST DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-6044
Mailing Address - Country:US
Mailing Address - Phone:810-288-8117
Mailing Address - Fax:707-767-7886
Practice Address - Street 1:2320 E 93RD ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3983
Practice Address - Country:US
Practice Address - Phone:773-978-2424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084737207P00000X
IL146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH65666Medicare UPIN