Provider Demographics
NPI: | 1245232198 |
---|---|
Name: | HICKS, MICHAEL J (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | J |
Last Name: | HICKS |
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: | 5000 COX RD |
Mailing Address - Street 2: | |
Mailing Address - City: | GLEN ALLEN |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23060-9263 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-968-5700 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4000 ROUTE 130 BLDG C |
Practice Address - Street 2: | |
Practice Address - City: | DELRAN |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08075-2414 |
Practice Address - Country: | US |
Practice Address - Phone: | 856-705-0685 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-08-11 |
Last Update Date: | 2022-02-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD023250E | 207P00000X |
NJ | 25MA09803100 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 0008913770010 | Medicaid | |
PA | 410456YEBK | Medicare PIN | |
PA | 410456YUNM | Medicare PIN | |
C33591 | Medicare UPIN | ||
PA | 0008913770010 | Medicaid |