Provider Demographics
NPI:1447221593
Name:MINSHEW, PHILIP TYLER (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:TYLER
Last Name:MINSHEW
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 1:2722 MERRILEE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4420
Mailing Address - Country:US
Mailing Address - Phone:703-698-4483
Mailing Address - Fax:703-573-0880
Practice Address - Street 1:2722 MERRILEE DR
Practice Address - Street 2:STE 230
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4420
Practice Address - Country:US
Practice Address - Phone:703-698-4483
Practice Address - Fax:703-573-0880
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA918172085R0202X
VA01012430522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00622666OtherRR MEDICARE
VA273522OtherKAISER PERMANENTE
VA0101243052OtherMEDICAL LICENSE
VA0104OtherCAREFIRST BCBS
WV3810011982Medicaid
DC003711F43Medicare PIN
DCP00622666OtherRR MEDICARE