Healthcare Provider Details

I. General information

NPI: 1730685405
Provider Name (Legal Business Name): PHILIP PANIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST
RICHMOND VA
23298-5023
US

IV. Provider business mailing address

PO BOX 780125
PHILADELPHIA PA
19178-0125
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-6600
  • Fax: 804-828-6129
Mailing address:
  • Phone: 804-922-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number2026036120
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101289331
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35C.004461
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35C.004461
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number43-53621
License Number StateKS
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDR.0072416
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: