Provider Demographics
NPI:1073562161
Name:UNTHANK, PHILLIP D (CRNA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:UNTHANK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19146 OUTER DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1863
Mailing Address - Country:US
Mailing Address - Phone:313-278-4026
Mailing Address - Fax:
Practice Address - Street 1:22401 FOSTER WINTER DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3724
Practice Address - Country:US
Practice Address - Phone:248-423-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704167210367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN97820007Medicare ID - Type Unspecified