1639269921 NPI number — DR. ANTHONY BERNARD MICKELSON MD

Table of content: DR. ANTHONY BERNARD MICKELSON MD (NPI 1639269921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639269921 NPI number — DR. ANTHONY BERNARD MICKELSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICKELSON
Provider First Name:
ANTHONY
Provider Middle Name:
BERNARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639269921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
USAMEDDAC WUERZBURG UNIT26610
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALS OFFICE
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
011499318043616
Provider Business Mailing Address Fax Number:
011499318043241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USAHC KATTERBACH
Provider Second Line Business Practice Location Address:
UNIT 28614
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09177
Provider Business Practice Location Address Country Code:
DE
Provider Business Practice Location Address Telephone Number:
01149981183811
Provider Business Practice Location Address Fax Number:
10049981183854
Provider Enumeration Date:
10/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  MD070474L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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