Basic Information
| Provider Information | |||||||||
| NPI: | 1912958075 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTICO | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 ACEE DRIVE | ||||||||
| Address2: | |||||||||
| City: | NATRONA HEIGHTS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002235544 | ||||||||
| FaxNumber: | 7242943206 | ||||||||
| Practice Location | |||||||||
| Address1: | HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | INDIANA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243577125 | ||||||||
| FaxNumber: | 7243577487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD013200E | PA | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085B0100X | MD013200E | PA | X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0904X | MD013200E | PA | X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | MD013200E | PA | X | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | MD013200E | PA | X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | MD013200E | PA | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 0006874530007 | 05 | PA | MEDICAID | 155732 | 01 | PA | HIGHMARK | OTHER |