Basic Information
| Provider Information | |||||||||
| NPI: | 1134137813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL L. HICKS, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758 | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838770758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087736400 | ||||||||
| FaxNumber: | 2087736800 | ||||||||
| Practice Location | |||||||||
| Address1: | 44405 WOODWARD AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483415023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488582270 | ||||||||
| FaxNumber: | 2483356171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HICKS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2488582270 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 4301406967 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
No ID Information.