Healthcare Provider Details

I. General information

NPI: 1891761821
Provider Name (Legal Business Name): ANTHONY PANICCIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19901 E 10 MILE RD
ST CLAIR SHORES MI
48080-1069
US

IV. Provider business mailing address

43800 GARFIELD RD SUITE 201
CLINTON TWP MI
48038-1136
US

V. Phone/Fax

Practice location:
  • Phone: 586-777-1277
  • Fax: 586-777-0106
Mailing address:
  • Phone: 800-848-0202
  • Fax: 586-226-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301070278
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: