1841782307 NPI number — PHILIP FISH M.D.

Table of content: PHILIP FISH M.D. (NPI 1841782307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841782307 NPI number — PHILIP FISH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISH
Provider First Name:
PHILIP
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1841782307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 N KEENE ST STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65201-8131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-499-4990
Provider Business Mailing Address Fax Number:
573-442-2120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 N KEENE ST STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65201-8131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-499-4990
Provider Business Practice Location Address Fax Number:
573-442-2120
Provider Enumeration Date:
05/31/2018

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: 208800000X , with the licence number:  390200000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 2023012283 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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