Provider Demographics
NPI:1245219344
Name:DECHRISTOPHER, PHILLIP (MD PHD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:DECHRISTOPHER
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:EMS BLDG., RM. 2209
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-3250
Mailing Address - Fax:708-216-2620
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:EMS BLDG., RM. 2209
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3250
Practice Address - Fax:708-216-2620
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36068429207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16217OtherMEDICARE
IL36068429Medicaid
ILK16217OtherMEDICARE
E18897Medicare UPIN