Provider Demographics
NPI:1427161306
Name:MICHAEL L. HICKS, MD, PC
Entity type:Organization
Organization Name:MICHAEL L. HICKS, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-760-2239
Mailing Address - Street 1:PO BOX 287
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:MA
Mailing Address - Zip Code:01775-0287
Mailing Address - Country:US
Mailing Address - Phone:978-897-4782
Mailing Address - Fax:978-897-2811
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:GUSTAFSON ASC, SUITE 202
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-2270
Practice Address - Fax:248-335-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406967207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P13110Medicare ID - Type Unspecified