Basic Information
| Provider Information | |||||||||
| NPI: | 1306822457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056286117 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N. WILSON ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147027915 | ||||||||
| FaxNumber: | 6149656534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37022 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.122335 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01370220 | 05 | OH | MEDICAID | P00685830 | 01 | AZ | RAILROAD MEDICARE | OTHER | 01370220 | 05 | CO | MEDICAID | 392564 | 05 | AZ | MEDICAID |