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General NPI Number Information
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NPI Number | 1578148375
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Entity Type | Organization
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Legal Business Name | MICHIGAN MSK MEDICINE PLLC
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Dates
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Enumeration Date | 03/12/2021
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Last Update Date | 07/25/2023
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Provider Practice Location Address
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Address Line | 36385 HARPER AVE
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48035-2958
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Country | US
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Telephone | 586-684-1900
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Fax | 586-684-1999
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Provider Business Mailing Address
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Address Line | 36385 HARPER AVE
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48035-2958
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAVID R HICKLING
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Credential | DO
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Telephone | 586-684-1900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204C00000X
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Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 204D00000X
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Taxonomy Name | Neuromusculoskeletal Medicine & OMM Physician
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License Number |
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License Number State |
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