Provider Demographics
NPI:1306911508
Name:HISCOCK, MICHAEL DAVID (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:HISCOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 33RD ST S STE 210
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9668
Mailing Address - Country:US
Mailing Address - Phone:320-240-6955
Mailing Address - Fax:320-240-8089
Practice Address - Street 1:1301 33RD ST S STE 210
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-9668
Practice Address - Country:US
Practice Address - Phone:320-240-6955
Practice Address - Fax:320-240-8089
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN011625400Medicaid
MN120L4HIOtherBLUE CROSS BLUE SHIELD
MNHP39133OtherHEALTHPARTNERS
MN264M1NOOtherBLUE CROSS BLUE SHIELD OF MN
MN6404175OtherMEDICA
MN6404175OtherSELECT CARE
MN264M1NOOtherBLUE CROSS BLUE SHIELD OF MN
MN6404175OtherSELECT CARE
MN650001038Medicare PIN