Healthcare Provider Details

I. General information

NPI: 1114917036
Provider Name (Legal Business Name): MICHELLE MARIE MILIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW PHC 5TH FLOOR
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

3800 RESERVOIR RD NW 4 MAIN
WASHINGTON DC
20007-2113
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-8830
  • Fax:
Mailing address:
  • Phone: 202-444-8830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number210137
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA105285
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD042553
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: