Basic Information
Provider Information | |||||||||
NPI: | 1861408155 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILICIA | ||||||||
FirstName: | ANTHONY | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2450 W HUNTING PARK AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191291302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157073008 | ||||||||
FaxNumber: | 2157071387 | ||||||||
Practice Location | |||||||||
Address1: | 3401 N BROAD ST | ||||||||
Address2: | 7TH FLOOR OUT PATIENT BUILDING | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191405103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157073008 | ||||||||
FaxNumber: | 2157071387 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 03/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | M2025288E | PA | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | MD025289E | PA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 0053032000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 467042 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1569008 | 01 | PA | AETNA HMO | OTHER | 30039504 | 01 | PA | KEYSTONE MERCY HEALTH | OTHER | 4328709 | 01 | PA | AETNA PPO | OTHER | P00360697 | 01 | PA | RAILROAD MEDICARE | OTHER | 001605953 | 05 | PA |   | MEDICAID | 4882 | 01 | PA | BRAVO HEALTH | OTHER |