Provider Demographics
NPI:1669434437
Name:KICKHAM, THOMAS C (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:KICKHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5708
Mailing Address - Country:US
Mailing Address - Phone:864-512-1335
Mailing Address - Fax:843-985-9562
Practice Address - Street 1:200 BOOKER DR
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:SC
Practice Address - Zip Code:29691-2278
Practice Address - Country:US
Practice Address - Phone:864-656-3076
Practice Address - Fax:843-985-9562
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC241207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000925306AMedicaid
SC002419Medicaid
NC89066G1Medicaid
SC002419Medicaid
GA000925306AMedicaid
SC930021886Medicare PIN