1922194166 NPI number — GEOFFREY M MILLICAN MD PA

Table of content: (NPI 1922194166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922194166 NPI number — GEOFFREY M MILLICAN MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEOFFREY M MILLICAN MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1922194166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4375 BOOTH CALLOWAY RD
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
NORTH RICHLAND HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76180-8359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-616-0700
Provider Business Mailing Address Fax Number:
817-616-0709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4375 BOOTH CALLOWAY RD
Provider Second Line Business Practice Location Address:
STE 400
Provider Business Practice Location Address City Name:
NORTH RICHLAND HILLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76180-8359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-616-0700
Provider Business Practice Location Address Fax Number:
817-617-0709
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLICAN
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DOCTOR-OWNER
Authorized Official Telephone Number:
817-616-0700

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  M3024 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M3024 . This is a "LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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