Healthcare Provider Details

I. General information

NPI: 1114000148
Provider Name (Legal Business Name): ACHINTYA MOULICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 A STREET
PHILADELPHIA PA
19134-1095
US

IV. Provider business mailing address

3601 A STREET
PHILADELPHIA PA
19134-1095
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-5109
  • Fax: 215-427-3860
Mailing address:
  • Phone: 215-427-5109
  • Fax: 215-427-3860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD035499
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: