Basic Information
Provider Information | |||||||||
NPI: | 1003822198 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HICKS | ||||||||
FirstName: | MARY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5200 DTC PKWY | ||||||||
Address2: | SUITE 400 | ||||||||
City: | GREENWOOD VILLAGE | ||||||||
State: | CO | ||||||||
PostalCode: | 801112709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037450000 | ||||||||
FaxNumber: | 3037081834 | ||||||||
Practice Location | |||||||||
Address1: | 5200 DTC PKWY | ||||||||
Address2: | SUITE 400 | ||||||||
City: | GREENWOOD VILLAGE | ||||||||
State: | CO | ||||||||
PostalCode: | 801112709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3037450000 | ||||||||
FaxNumber: | 3037081834 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 05/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 45326 | CO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 036112109 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 45326 | CO | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 7215059 | 01 | IL | BCBS PPO | OTHER | 0361121092 | 05 | IL |   | MEDICAID | 105682 | 01 | IL | HEALTH ALLIANCE | OTHER | 623665 | 01 | IL | HEALTHLINK | OTHER | IL01V7 | 01 | IL | JOHN DEERE | OTHER | P00281865 | 01 | IL | RAILROAD MEDICARE | OTHER | 46379576 | 05 | CO |   | MEDICAID |