Provider Demographics
NPI:1720181738
Name:LICKEY, HAROLD MARK (MD)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:MARK
Last Name:LICKEY
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 1:2400 PATTERSON ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1562
Mailing Address - Country:US
Mailing Address - Phone:615-327-7400
Mailing Address - Fax:615-327-4818
Practice Address - Street 1:2400 PATTERSON ST
Practice Address - Street 2:SUITE 500
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1562
Practice Address - Country:US
Practice Address - Phone:615-327-7400
Practice Address - Fax:615-327-4818
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILM8231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806166600Medicaid
H45730Medicare UPIN
1102183Medicare ID - Type Unspecified