Provider Demographics
NPI:1902034515
Name:PANICO, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PANICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1199 PRINCE AVE
Mailing Address - Street 2:MIND BODY INSTITUTE
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2797
Mailing Address - Country:US
Mailing Address - Phone:706-475-4722
Mailing Address - Fax:706-475-6717
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:MIND BODY INSTITUTE
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2797
Practice Address - Country:US
Practice Address - Phone:706-475-4722
Practice Address - Fax:706-475-6717
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0178702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDHWNMedicare PIN
GAD40799Medicare UPIN