Provider Demographics
NPI:1285686055
Name:HICKEY, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:HICKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1325 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2158
Mailing Address - Country:US
Mailing Address - Phone:817-332-9957
Mailing Address - Fax:817-336-3130
Practice Address - Street 1:1325 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2158
Practice Address - Country:US
Practice Address - Phone:817-332-9957
Practice Address - Fax:817-336-3130
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG41322086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142236201Medicaid
TX142236201Medicaid
TXA37650Medicare UPIN