Provider Demographics
NPI:1891761821
Name:PANICCIA, ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:PANICCIA
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 1:43800 GARFIELD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:19901 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1069
Practice Address - Country:US
Practice Address - Phone:586-777-1277
Practice Address - Fax:586-777-0106
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070278207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P27380OtherMEDICARE GROUP LEGACY #
MI4588604Medicaid
MI0501046OtherBCBS PIN
MI0P27380OtherMEDICARE GROUP LEGACY #
H19562Medicare UPIN
MI4588604Medicaid
P27380002Medicare ID - Type Unspecified