Healthcare Provider Details

I. General information

NPI: 1306762661
Provider Name (Legal Business Name): MICHAEL BERNARD HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL BERNARD HICKS

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 ROSE LN # WI53004
BELGIUM WI
53004-9548
US

IV. Provider business mailing address

109 ROSE LN # WI53004
BELGIUM WI
53004-9548
US

V. Phone/Fax

Practice location:
  • Phone: 414-841-1114
  • Fax: 414-841-1114
Mailing address:
  • Phone: 414-841-1114
  • Fax: 414-841-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number101Y000008
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: