Provider Demographics
NPI:1073508040
Name:BRITTAIN, PHILIP CLARK (DO)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:CLARK
Last Name:BRITTAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 S WALKER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2158
Mailing Address - Country:US
Mailing Address - Phone:812-331-9160
Mailing Address - Fax:812-336-0277
Practice Address - Street 1:642 S WALKER ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2158
Practice Address - Country:US
Practice Address - Phone:812-331-9160
Practice Address - Fax:812-336-0277
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001508207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200016270Medicaid
D24093Medicare UPIN
IN200016270Medicaid
IN200016270Medicaid