Provider Demographics
NPI:1922194166
Name:GEOFFREY M MILLICAN MD PA
Entity Type:Organization
Organization Name:GEOFFREY M MILLICAN MD PA
Other - Org Name:GEOFFREY M MILLICAN MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLICAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-616-0700
Mailing Address - Street 1:4375 BOOTH CALLOWAY RD
Mailing Address - Street 2:STE 400
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-8359
Mailing Address - Country:US
Mailing Address - Phone:817-616-0700
Mailing Address - Fax:817-616-0709
Practice Address - Street 1:4375 BOOTH CALLOWAY RD
Practice Address - Street 2:STE 400
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-8359
Practice Address - Country:US
Practice Address - Phone:817-616-0700
Practice Address - Fax:817-617-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3024207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM3024OtherLICENSE NUMBER
TX=========OtherTAX ID NUMBER