Provider Demographics
NPI:1639112667
Name:MILLICAN, JAMES TONY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:TONY
Last Name:MILLICAN
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALIN/PAYER CONTRACTING
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-8780
Practice Address - Fax:313-436-2864
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-03-21
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Provider Licenses
StateLicense IDTaxonomies
MI4301081866207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1639112667Medicaid
11614815OtherCAQH
MII53832Medicare UPIN