Provider Demographics
NPI:1942531835
Name:MICHAEL J. & BEVERLY HICKS
Entity Type:Organization
Organization Name:MICHAEL J. & BEVERLY HICKS
Other - Org Name:AUDIOLOGY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/AUDIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:AUD, CCC-A
Authorized Official - Phone:618-524-2176
Mailing Address - Street 1:28 CHICK ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2467
Mailing Address - Country:US
Mailing Address - Phone:618-524-2176
Mailing Address - Fax:618-564-3206
Practice Address - Street 1:28 CHICK ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2467
Practice Address - Country:US
Practice Address - Phone:618-524-2176
Practice Address - Fax:618-564-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-17
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-000631231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K45767Medicare UPIN