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Benjamin Matthew Hicks

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NPI Number Detailed Information

Provider Information:

Name: Benjamin Matthew Hicks
Gender: M
Provider License Number If Given: 01046509A

NPI Information:

NPI: 1780687707
Entity Type
(Individual or Organization):
1-ind
Enumeration Date: 5/23/2005

Last Update Date: 11/3/2016

Provider Business Mailing Address:

Address: PO BOX 2526
Fort Wayne, IN 46801
Phone Number: 2604368686
Fax Number: 2604368585

Provider Business Practice Location Address:

Address: 7601 W JEFFERSON BLVD
Fort Wayne, IN 46804
Phone Number: 2604368686
Fax Number: 2604368585

Provider Taxonomy:

Primary: 207X00000X
Secondary (if any): 207XX0801X
State: IN

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