Provider Demographics
NPI:1427106624
Name:HICKS, KEVIN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300A TEMPLE LAKE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2972
Mailing Address - Country:US
Mailing Address - Phone:804-524-2400
Mailing Address - Fax:804-526-1852
Practice Address - Street 1:300A TEMPLE LAKE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2972
Practice Address - Country:US
Practice Address - Phone:804-524-2400
Practice Address - Fax:804-526-1852
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH23433207RR0500X
VA0101238458207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1427106624Medicaid
H19898Medicare UPIN