Provider Demographics
NPI:1801849591
Name:HICKS, ROBERT MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:HICKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13700-1378
Mailing Address - Street 2:BROOKHAVEN MEMORIAL HOSPITAL - ER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19191-1378
Mailing Address - Country:US
Mailing Address - Phone:800-666-2455
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:101 HOSPITAL ROAD
Practice Address - Street 2:MEDICAL CENTER
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-687-7236
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY005303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S85195Medicare UPIN
0F4081Medicare ID - Type Unspecified