Provider Demographics
NPI:1043201551
Name:HICKS, SUSAN K (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:HICKS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-2560
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2221 HEALTH DR SW STE 2100
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-252-4410
Practice Address - Fax:616-252-4480
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISH012674174400000X
MI5101012674207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16042016Medicare ID - Type Unspecified
MI4237510Medicaid
MIH17999Medicare UPIN