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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 |
