Provider Demographics
NPI:1225080625
Name:PHILLIPS, VALESIA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:VALESIA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 SOUTH MICHIGAN AVENUE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3484
Mailing Address - Country:US
Mailing Address - Phone:312-808-1600
Mailing Address - Fax:312-808-0985
Practice Address - Street 1:2930 SOUTH MICHIGAN AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3484
Practice Address - Country:US
Practice Address - Phone:312-808-1600
Practice Address - Fax:312-808-0985
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G52615Medicare UPIN
261410Medicare ID - Type Unspecified