| Stuart Hickerson, | |
|
12528 Sr 78, Havana, IL 62644-6866 | |
| (309) 543-4253 | |
| Not Available |
| Full Name | Stuart Hickerson |
|---|---|
| Gender | Male |
| Speciality | Emergency Medicine |
| Location | 12528 Sr 78, Havana, Illinois |
| Accepts Medicare Assignments | Medicare enrolled and may accept medicare through third-party reassignment. May prescribe medicare part D drugs. |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1073629374 | NPI | - | NPPES |
| 036083126 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207P00000X | Emergency Medicine | 036083126 (Illinois) | Primary |
| 207PE0004X | Emergency Medicine - Emergency Medical Services | 036083126 (Illinois) | Secondary |
| Entity Name | Methodist Medical Center Of Illinois |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1982656575 PECOS PAC ID: 1355259714 Enrollment ID: O20031126000494 |
| Entity Name | Mcdonough County Hospital District |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1669420766 PECOS PAC ID: 0446140180 Enrollment ID: O20040611000228 |
| Entity Name | Osf Healthcare System |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1679606073 PECOS PAC ID: 4284541806 Enrollment ID: O20070503000249 |
| Entity Name | Epss Peoria Llc |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1831421056 PECOS PAC ID: 1850587007 Enrollment ID: O20101130000569 |
| Entity Name | Methodist Medical Center Of Illinois |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1265966048 PECOS PAC ID: 1355259714 Enrollment ID: O20170828003194 |
| Entity Name | Epss Llc - Central Series |
|---|---|
| Entity Type | Part B Supplier - Clinic/group Practice |
| Entity Identifiers | NPI Number: 1538680467 PECOS PAC ID: 6204192016 Enrollment ID: O20171110002604 |
| Mailing Address | Practice Location Address |
|---|---|
| Stuart Hickerson, 3333 N Seminary St, Galesburg, IL 61401-1251 Ph: () - | Stuart Hickerson, 12528 Sr 78, Havana, IL 62644-6866 Ph: (309) 543-4253 |