Basic Information
| Provider Information | |||||||||
| NPI: | 1619917788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKMAN | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 THIRD ST | ||||||||
| Address2: | |||||||||
| City: | BORDENTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085051321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092982005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23203 COLUMBUS RD STE I | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080221985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093034450 | ||||||||
| FaxNumber: | 6093034451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD072498L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25MA10235700 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1301488 | 01 | PA | HIGHMARK | OTHER | 0018417270004 | 05 | PA | MEDICAID |