1891081386 NPI number — CHRISTOPHER M PHILLIPS DPM.

Table of content: CHRISTOPHER M PHILLIPS DPM. (NPI 1891081386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891081386 NPI number — CHRISTOPHER M PHILLIPS DPM.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHILLIPS
Provider First Name:
CHRISTOPHER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM.
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:
1891081386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1086
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLOUGHBY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44096-1086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-645-7242
Provider Business Mailing Address Fax Number:
440-975-8278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4520 CENTERVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55127-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-426-3995
Provider Business Practice Location Address Fax Number:
651-426-5626
Provider Enumeration Date:
06/22/2011

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: 213ES0103X , with the licence number:  923 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 472603200 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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