Provider Demographics
NPI:1104828763
Name:DIVELBISS, PHILIP MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:MARK
Last Name:DIVELBISS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19414 LEITERSBURG PIKE
Mailing Address - Street 2:SUITE E
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-7601
Mailing Address - Country:US
Mailing Address - Phone:301-739-2987
Mailing Address - Fax:301-739-7664
Practice Address - Street 1:19414 LEITERSBURG PIKE
Practice Address - Street 2:SUITE E
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-7601
Practice Address - Country:US
Practice Address - Phone:301-739-2987
Practice Address - Fax:301-739-7664
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T9550001OtherBLUE CHOICE MD DC
T9550001OtherBLUE CHOICE MD DC
M202Medicare ID - Type Unspecified