NPIMap

Individual provider Active NPI

Simon Leo Lick, M.D.

  • Internal Medicine Physician
  • Grand Rapids, MN
National Provider Identifier
1922238823
Registry record updated Sep 20, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
54954 Issued in MN
Practice address
1601 Golf Course Rd
Grand Rapids, MN 55744-8648
Phone
(218) 326-3401
NPI assigned
Jul 26, 2009
Last updated
Sep 20, 2018By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 20, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 54954 MN Primary

Addresses

Primary practice location

1601 Golf Course Rd
Grand Rapids, MN 55744-8648

Mailing address

1601 Golf Course Rd
Grand Rapids, MN 55744-8648
Phone (218) 326-3401

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20120717000514 MN Practitioner - Internal Medicine 5092971176 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
University of Minnesota Medical School, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Grand Itasca Clinic and HospitalGroup PAC ID 8123939550, 328 clinicians
Range Regional Health ServicesGroup PAC ID 8022920024, 349 clinicians

Practice addresses (Care Compare)

1601 Golf Course Rd
Grand Rapids, MN 55744-8648
Phone (218) 326-3401

750 E 34TH St
Hibbing, MN 55746-4600
Phone (218) 262-4881

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
92.35 of 100Reported as group
Quality
88.69
Promoting interoperability
100
Improvement activities
40
Cost
76.65

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
54954MNMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Grand Itasca Clinic and Hospital CurrentSince Jul 1, 2012 Accepting new patients
Range Regional Health Services CurrentSince Apr 1, 2025 Accepting new patients
Grand Itasca Clinic and Hospital CurrentSince Jul 1, 2012 Accepting new patients
Range Regional Health Services Current Accepting new patients
Range Regional Health Services CurrentSince Apr 1, 2025 Accepting new patients

Locations

111 SE 3rd St
Grand Rapids, MN 55744
Phone (218) 326-3401

126 SE 1st Ave
Grand Rapids, MN 55744
Phone (218) 326-3401

1601 Golf Course Rd
Grand Rapids, MN 55744
Phone (218) 326-3401

750 E 34th St
Hibbing, MN 55746
Phone (218) 262-3441

402 E Platt Ave
Nashwauk, MN 55769
Phone (218) 885-2858

Interoperability endpoints

  • Direct secure messaging: slick83639@fairview.direct-ci.com

Ownership & related parties

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Grand Itasca Clinic and HospitalGrand Rapids, MN, CCN 240064A Hospital Corporate Director Jan 1, 2020
Grand Itasca Home CareGrand Rapids, MN, CCN 247286 Home health agency Corporate Director Jan 1, 2020

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1248566400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1537401600000",
    "number": "1922238823",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1601 GOLF COURSE RD",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "557448648",
            "telephone_number": "218-326-3401"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1601 GOLF COURSE RD",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "557448648",
            "telephone_number": "218-326-3401"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LICK",
        "first_name": "SIMON",
        "middle_name": "LEO",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-07-26",
        "last_updated": "2018-09-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MN",
            "license": "54954",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MN

Sources for this page

Verify at the official NPI Registry.