Provider Demographics
NPI:1073583308
Name:PHELPS, MICHAEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:PHELPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1228 E RUSHOLME ST
Mailing Address - Street 2:SUITE 3020
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803
Mailing Address - Country:US
Mailing Address - Phone:563-823-9300
Mailing Address - Fax:563-823-9330
Practice Address - Street 1:1228 E RUSHOLME ST
Practice Address - Street 2:SUITE 3020
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803
Practice Address - Country:US
Practice Address - Phone:563-823-9300
Practice Address - Fax:563-823-9330
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA27450208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2062455Medicaid
E46601Medicare UPIN
148627Medicare ID - Type Unspecified