Provider Demographics
NPI:1619139714
Name:EARL T HECKER D.O. P.C.
Entity Type:Organization
Organization Name:EARL T HECKER D.O. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRYSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-471-8828
Mailing Address - Street 1:28080 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5966
Mailing Address - Country:US
Mailing Address - Phone:248-471-8828
Mailing Address - Fax:248-471-8486
Practice Address - Street 1:28080 GRAND RIVER AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:248-471-8828
Practice Address - Fax:248-471-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEH005377174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1769105Medicaid
MIE31655Medicare UPIN
MI5632906Medicare PIN