Basic Information
| Provider Information | |||||||||
| NPI: | 1013085752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANTELIC | ||||||||
| FirstName: | MILAN | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
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| Practice Location | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | 4301052765 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 4301052765 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 700H262300 | 01 | BLUE CROSS-BLUE CROSS | OTHER | 283987710 | 05 | MI | MEDICAID | MP052765 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | MP052765 | 01 | CHAMPUS-CHAMPUS | OTHER |