Provider Demographics
NPI:1487670733
Name:JACK R. MILLIGAN M.D., P.A.
Entity Type:Organization
Organization Name:JACK R. MILLIGAN M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-735-7730
Mailing Address - Street 1:766 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4146
Mailing Address - Country:US
Mailing Address - Phone:302-735-7730
Mailing Address - Fax:302-735-4911
Practice Address - Street 1:766 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4146
Practice Address - Country:US
Practice Address - Phone:302-735-7730
Practice Address - Fax:302-735-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001019401Medicaid
DE490751Medicare ID - Type Unspecified
DE0001019401Medicaid