Provider Demographics
NPI:1003115577
Name:STEPHEN A. HICKNER, M.D., LLC
Entity Type:Organization
Organization Name:STEPHEN A. HICKNER, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HICKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-633-8628
Mailing Address - Street 1:8160 HIGHWAY 789
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2953
Mailing Address - Country:US
Mailing Address - Phone:616-633-8628
Mailing Address - Fax:
Practice Address - Street 1:8160 HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2953
Practice Address - Country:US
Practice Address - Phone:616-633-8628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL1524207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty