Provider Demographics
NPI:1255366217
Name:HICKS, PAUL SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:SAMUEL
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:600 IVY ST STE 205
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1627
Practice Address - Country:US
Practice Address - Phone:607-737-4333
Practice Address - Fax:607-737-4271
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY169764207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01415750Medicaid
PA001194150Medicaid
NYJ400066938Medicare PIN
060012696Medicare ID - Type UnspecifiedRR MEDICARE ID#
NY01415750Medicaid
NY01415750Medicaid