Provider Demographics
NPI:1083721609
Name:HICKMAN, BRUCE EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:HICKMAN
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1640 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027
Practice Address - Country:US
Practice Address - Phone:262-670-4000
Practice Address - Fax:262-670-4451
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01115320OtherRR MEDICARE
WI462364825Medicare PIN
H01902Medicare UPIN
WIP01115320OtherRR MEDICARE