Provider Demographics
NPI:1992717763
Name:HICKLIN, HARRY EUGENE III (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:EUGENE
Last Name:HICKLIN
Suffix:III
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 1:430 S HERLONG AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1094
Mailing Address - Country:US
Mailing Address - Phone:803-324-4900
Mailing Address - Fax:803-324-1155
Practice Address - Street 1:430 S HERLONG AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1094
Practice Address - Country:US
Practice Address - Phone:803-324-4900
Practice Address - Fax:803-324-1155
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14159207R00000X, 207RC0000X
NC39615207R00000X, 207RC0000X
IA25618207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC141590Medicaid
SCP00204305OtherRAILROAD MEDICARE
NC8942145Medicaid
NC42145OtherBCBS
NCP00200607OtherRAILROAD MEDICARE
SC141590Medicaid
NCP00200607OtherRAILROAD MEDICARE
SCE787438186Medicare PIN