Provider Demographics
NPI:1326097288
Name:WITHNELL, PHILIP LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:LEIGH
Last Name:WITHNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-1114
Mailing Address - Country:US
Mailing Address - Phone:330-875-5544
Mailing Address - Fax:330-875-8150
Practice Address - Street 1:1302 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1114
Practice Address - Country:US
Practice Address - Phone:330-875-5544
Practice Address - Fax:330-875-8150
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2070226Medicaid
OHH053250Medicare PIN
H19582Medicare UPIN