1336104835 NPI number — MICHAEL G HICKEY P.A.

Table of content: MICHAEL G HICKEY P.A. (NPI 1336104835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336104835 NPI number — MICHAEL G HICKEY P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKEY
Provider First Name:
MICHAEL
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336104835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8310
Provider Second Line Business Mailing Address:
VIRIGNIA EMERGENCY ASSOCIATES INC
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-0310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-345-3556
Provider Business Mailing Address Fax Number:
540-342-2193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1402 MAIN ST
Provider Second Line Business Practice Location Address:
DRMC ED
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-287-7066
Provider Business Practice Location Address Fax Number:
804-673-9531
Provider Enumeration Date:
04/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  0110840453 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0110840453 . This is a "BOARD OF MEDICINE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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