Basic Information
| Provider Information | |||||||||
| NPI: | 1669434437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KICKHAM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 N FANT ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296215708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645121335 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 BOOKER DR | ||||||||
| Address2: | |||||||||
| City: | WALHALLA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296912278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646563076 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 241 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208D00000X | 241 | SC | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 89066G1 | 05 | NC | MEDICAID | 000925306A | 05 | GA | MEDICAID | 002419 | 05 | SC | MEDICAID |