Basic Information
| Provider Information | |||||||||
| NPI: | 1356343941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKEY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2223 PARKERS HILL DR | ||||||||
| Address2: | |||||||||
| City: | MAIDENS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231022244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045565170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5801 BREMO RD | ||||||||
| Address2: | ST FRANCIS EMERGENCY DEPARTMENT | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042877066 | ||||||||
| FaxNumber: | 8046739531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 04/27/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0101233603 | VA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 114228 | 01 | VA | BLUE SHILED | OTHER | 204990 | 01 | VA | BLUE SHIELD | OTHER | 232562 | 01 | VA | BLUE SHIELD | OTHER | 114708 | 01 | VA | BLUE SHIELD | OTHER | 1356343941 | 05 | VA | MEDICAID | 234124 | 01 | VA | BLUE SHIELD | OTHER |