1568568632 NPI number — SHAILAJA M PHILIP MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568568632 NPI number — SHAILAJA M PHILIP MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

PHILIP

Provider First Name:

SHAILAJA

Provider Middle Name:

M

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1568568632

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/30/2009

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 99213

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

FORT WORTH

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

76199-0213

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

682-885-4433

Provider Business Mailing Address Fax Number:

682-885-3939

Provider First Line Business Practice Location Address:

712 7TH AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

FORT WORTH

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

76104-2703

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

682-885-1024

Provider Business Practice Location Address Fax Number:

682-885-1033

Provider Enumeration Date:

09/16/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208000000X , with the licence number:  M0866 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 003GS . This is a "BCBSTX GRP PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 175593601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 080626701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 16331401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 8B2076 . This is a "BCBSTX IND PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 1003887985 . This is a "GRP NPI NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 170994101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 7529393 . This is a "AETNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 175593602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 175593603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 8818814 . This is a "CIGNA PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: F67550 . This is a "PRONET PIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".