Provider Demographics
NPI:1255353298
Name:PORT CITY ORTHOPAEDICS PLLC
Entity type:Organization
Organization Name:PORT CITY ORTHOPAEDICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-791-4492
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28480-0232
Mailing Address - Country:US
Mailing Address - Phone:910-791-4492
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:206 CAUSEWAY DR UNIT 232
Practice Address - Street 2:
Practice Address - City:WRIGHTSVILLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28480-1759
Practice Address - Country:US
Practice Address - Phone:910-791-4492
Practice Address - Fax:000-000-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2663410OtherUHC
NC018FWOtherBCBSNC
NC5904704Medicaid
DF1406OtherMEDICARE RR
2663410OtherUHC
3327498OtherCIGNA
DF1406OtherMEDICARE RR
NC5904704Medicaid