Basic Information
Provider Information | |||||||||
NPI: | 1528027422 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLIGAN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | DARRELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 30532 | ||||||||
Address2: |   | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325031532 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8509163700 | ||||||||
FaxNumber: | 8509163710 | ||||||||
Practice Location | |||||||||
Address1: | 1040 GULF BREEZE PKWY | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GULF BREEZE | ||||||||
State: | FL | ||||||||
PostalCode: | 325617808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8509163700 | ||||||||
FaxNumber: | 8509163710 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2006 | ||||||||
LastUpdateDate: | 11/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200200257 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QS0010X | 11818 | NV | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | ME125304 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 178196 | 05 | AL |   | MEDICAID |