Provider Demographics
NPI:1457391005
Name:HICKEY, GREGORY G (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:HICKEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30575 BAINBRIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2275
Mailing Address - Country:US
Mailing Address - Phone:440-542-5000
Mailing Address - Fax:440-542-5005
Practice Address - Street 1:30575 BAINBRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44139-2275
Practice Address - Country:US
Practice Address - Phone:440-542-5000
Practice Address - Fax:440-542-5005
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003908207RC0200X
OH34-003908207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0841325Medicaid
OH290008878OtherRAILROAD MEDICARE
OHHI0694504Medicare PIN
OHE88174Medicare UPIN