Provider Demographics
NPI:1376509851
Name:HICKS, RANDY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DAVID
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 1:3346 LENNON ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1015
Mailing Address - Country:US
Mailing Address - Phone:810-244-7109
Mailing Address - Fax:810-732-3740
Practice Address - Street 1:3346 LENNON ROAD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1015
Practice Address - Country:US
Practice Address - Phone:810-732-1919
Practice Address - Fax:810-732-3740
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048682174400000X, 2085R0202X
OH350912562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
F01308Medicare UPIN
MI0B56294002Medicare ID - Type UnspecifiedMEDICARE NUMBER
MIF01308Medicare UPIN