Provider Demographics
NPI:1043320278
Name:FRACICA, PHILIP J (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:FRACICA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 14TH ST
Mailing Address - Street 2:PO BOX 1706
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5972
Mailing Address - Country:US
Mailing Address - Phone:660-827-9488
Mailing Address - Fax:
Practice Address - Street 1:601 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5972
Practice Address - Country:US
Practice Address - Phone:660-827-9488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22761207RP1001X
MO2008007036207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ171843Medicaid
AZC83857Medicare UPIN
AZC83857Medicare UPIN