Healthcare Provider Details

I. General information

NPI: 1548753619
Provider Name (Legal Business Name): MEREDITH ROSE HICKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE RM 280
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-0118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301512126
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: