Healthcare Provider Details

I. General information

NPI: 1073629374
Provider Name (Legal Business Name): STUART HICKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12528 SR 78
HAVANA IL
62644-6866
US

IV. Provider business mailing address

3333 N SEMINARY ST
GALESBURG IL
61401-1251
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-4253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036083126
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036083126
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: