Healthcare Provider Details

I. General information

NPI: 1316595747
Provider Name (Legal Business Name): MICHAEL ANTHONY HUYCK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 09/07/2020
Certification Date: 09/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 W DIVISION ST
CHICAGO IL
60651-2405
US

IV. Provider business mailing address

2301 HAINSWORTH AVE
NORTH RIVERSIDE IL
60546-1328
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-7425
  • Fax:
Mailing address:
  • Phone: 773-621-7775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041408668
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021549
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: