1821027756 NPI number — JACQUELINE PHILLIPS DPM INC

Table of content: (NPI 1821027756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821027756 NPI number — JACQUELINE PHILLIPS DPM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQUELINE PHILLIPS DPM INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1821027756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5575 CONNER ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48213-6400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-345-4449
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5575 CONNER ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48213-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-345-4449
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
313-345-4449

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  5901001422 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 5901001422 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 480H232340 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 134313228 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".