Basic Information
| Provider Information | |||||||||
| NPI: | 1265579197 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKEY | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1184 STATE RT 50 | ||||||||
| Address2: | |||||||||
| City: | BALLSTON LAKE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183841281 | ||||||||
| FaxNumber: | 5183840321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 229140 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 229140 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02644113 | 05 | NY | MEDICAID |