Provider Demographics
NPI:1033695325
Name:PHILLIPS, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-0869
Mailing Address - Country:US
Mailing Address - Phone:618-252-0275
Mailing Address - Fax:618-252-2389
Practice Address - Street 1:22 VETERANS DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-3320
Practice Address - Country:US
Practice Address - Phone:618-252-0275
Practice Address - Fax:618-252-2389
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid