Provider Demographics
NPI:1407961923
Name:K J PHILIP MDSC
Entity Type:Organization
Organization Name:K J PHILIP MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:K
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-475-6063
Mailing Address - Street 1:800 AUSTIN ST
Mailing Address - Street 2:SUITE 607
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3439
Mailing Address - Country:US
Mailing Address - Phone:847-475-6063
Mailing Address - Fax:847-475-6065
Practice Address - Street 1:800 AUSTIN ST
Practice Address - Street 2:SUITE 607
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3439
Practice Address - Country:US
Practice Address - Phone:847-475-6063
Practice Address - Fax:847-475-6065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1239930001Medicare NSC
ILL74226Medicare UPIN