Provider Demographics
NPI:1386628196
Name:HICHME, JENNIFER L (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:HICHME
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LISA
Other - Last Name:BAUSTERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:43455 SCHOENHERR RD
Mailing Address - Street 2:STE 2
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313
Mailing Address - Country:US
Mailing Address - Phone:586-726-4823
Mailing Address - Fax:586-726-8365
Practice Address - Street 1:43455 SCHOENHERR RD
Practice Address - Street 2:STE 2
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313
Practice Address - Country:US
Practice Address - Phone:586-726-4823
Practice Address - Fax:586-726-8365
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4113601Medicaid
MI4113601Medicaid
OF37078Medicare ID - Type Unspecified