Provider Demographics
NPI:1013973601
Name:HISCOCK, JAMES T (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:HISCOCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78000
Mailing Address - Street 2:DEPT. 78415
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-0415
Mailing Address - Country:US
Mailing Address - Phone:810-262-9953
Mailing Address - Fax:810-760-0440
Practice Address - Street 1:ONE HURLEY PLAZA
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5993
Practice Address - Country:US
Practice Address - Phone:810-262-9953
Practice Address - Fax:810-760-0440
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704208184207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104397550Medicaid
MIN47230006Medicare ID - Type UnspecifiedLOC 99
MI104397550Medicaid
0B56166Medicare PIN