Provider Demographics
NPI:1336153881
Name:HICKEY, KATHLEEN ANN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10660 PARK RD
Practice Address - Street 2:STE 4400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8413
Practice Address - Country:US
Practice Address - Phone:704-667-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01953207P00000X, 208600000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2243Medicaid
NJ7655606Medicaid
NC1336153881Medicaid
SCNC2243Medicaid
NCNCK874AMedicare PIN
NCNCK874C904Medicare PIN
NC1336153881Medicaid