Provider Demographics
NPI:1386699098
Name:HICKNER, STEPHEN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANDREW
Last Name:HICKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR STE L2200
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-930-4020
Mailing Address - Fax:734-769-8948
Practice Address - Street 1:24 FRANK LLOYD WRIGHT DR STE L2200
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9484
Practice Address - Country:US
Practice Address - Phone:734-930-4020
Practice Address - Fax:734-769-8948
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057359207V00000X
CO49335207V00000X
WY8674A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901070Medicaid
MI4877311Medicaid
MI3105697Medicaid
MI4878954Medicaid
MI4108737Medicaid
MI2901070Medicaid
MIM02830104Medicare ID - Type Unspecified
P32930079Medicare ID - Type Unspecified
MI4877311Medicaid