Healthcare Provider Details

I. General information

NPI: 1306911508
Provider Name (Legal Business Name): MICHAEL DAVID HISCOCK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 33RD ST S STE 210
SAINT CLOUD MN
56301-9668
US

IV. Provider business mailing address

1301 33RD ST S STE 210
SAINT CLOUD MN
56301-9668
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-6955
  • Fax: 320-240-8089
Mailing address:
  • Phone: 320-240-6955
  • Fax: 320-240-8089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7234
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: