Provider Demographics
NPI:1114965225
Name:ROSSI, PHILLIP JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JOSEPH
Last Name:ROSSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:107 TREMONT ST
Mailing Address - City:HOPEDALE
Mailing Address - State:IL
Mailing Address - Zip Code:61747-0267
Mailing Address - Country:US
Mailing Address - Phone:309-449-4450
Mailing Address - Fax:309-449-4488
Practice Address - Street 1:107 TREMONT ST
Practice Address - Street 2:MEDICAL ARTS PHYSICIANS
Practice Address - City:HOPEDALE
Practice Address - State:IL
Practice Address - Zip Code:61747-0267
Practice Address - Country:US
Practice Address - Phone:309-449-4450
Practice Address - Fax:309-449-4488
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088911208D00000X, 208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088911Medicaid
345640Medicare PIN
IL036088911Medicaid