Basic Information
| Provider Information | |||||||||
| NPI: | 1023049657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAILIDIS | ||||||||
| FirstName: | SOPHIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 NORTH ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 NORTH ACADEMY AVE. | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178222111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716439 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS008048L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QB0002X | 246455 | MA | N | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | MI464401 | 01 | PA | MEDICARE | OTHER |