1811970478 NPI number — MR. JONATHAN C HICKLIN MD

Table of content: MR. JONATHAN C HICKLIN MD (NPI 1811970478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811970478 NPI number — MR. JONATHAN C HICKLIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKLIN
Provider First Name:
JONATHAN
Provider Middle Name:
C
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1811970478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1565 EBENEZER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCK HILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29732-1806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-328-0168
Provider Business Mailing Address Fax Number:
803-325-8473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1565 EBENEZER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-1806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-328-0168
Provider Business Practice Location Address Fax Number:
803-325-8473
Provider Enumeration Date:
11/28/2005

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: 207W00000X , with the licence number:  17919 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: T21544 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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