1710938725 NPI number — THEODORE GEORGE PHILLIPS MD

Table of content: THEODORE GEORGE PHILLIPS MD (NPI 1710938725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710938725 NPI number — THEODORE GEORGE PHILLIPS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
THEODORE
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710938725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 783311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19178-3311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-884-4500
Provider Business Mailing Address Fax Number:
484-884-0699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 S CEDAR CREST BLVD
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18103-6224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-402-6890
Provider Business Practice Location Address Fax Number:
610-402-6892
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  MD041580L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000637659 . This is a "KEYSTONE EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 50039540 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 637659 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 637659 . This is a "KEYSTONE CENTRAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0012385870005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1511814 . This is a "GATEWAY HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 35920 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00192724 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0467898000 . This is a "AMERIHEALTH (IBC)" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 20034834 . This is a "AMERIHEALTH MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30022212 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3641356 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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