1366407439 NPI number — DR. BRADLEY WILLIAM HICKEY M.D.

Table of content: DR. BRADLEY WILLIAM HICKEY M.D. (NPI 1366407439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366407439 NPI number — DR. BRADLEY WILLIAM HICKEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKEY
Provider First Name:
BRADLEY
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366407439
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 S CRAG RD
Provider Second Line Business Mailing Address:
NAVAL DIVING AND SALVAGE TRAINING CENTER
Provider Business Mailing Address City Name:
PANAMA CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-235-5217
Provider Business Mailing Address Fax Number:
850-235-5993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NAVAL OPERATIONAL MEDICINE INSTITUTE
Provider Second Line Business Practice Location Address:
220 HOVEY RD
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32508-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-452-9484
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083P0011X , with the licence number:  E-4165 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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