Provider Demographics
NPI:1871573196
Name:HICKS, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:1100 KERMIT DR
Mailing Address - Street 2:STE 106
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-2121
Mailing Address - Country:US
Mailing Address - Phone:615-361-6953
Mailing Address - Fax:615-360-0947
Practice Address - Street 1:1100 KERMIT DR
Practice Address - Street 2:STE 106
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37217-2121
Practice Address - Country:US
Practice Address - Phone:615-361-6953
Practice Address - Fax:615-360-0947
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000011486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3186178Medicaid
TN3186178Medicaid
B04229Medicare UPIN