Provider Demographics
NPI:1497028526
Name:COURTNEY, PHILLIP D
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:COURTNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670811
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-0811
Mailing Address - Country:US
Mailing Address - Phone:907-688-0731
Mailing Address - Fax:
Practice Address - Street 1:18708 SUE TAWN DRIVE
Practice Address - Street 2:
Practice Address - City:CHUGIAK
Practice Address - State:AK
Practice Address - Zip Code:99567
Practice Address - Country:US
Practice Address - Phone:907-688-0731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 171WV0202X
AK24301171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171W00000XOther Service ProvidersContractor
No171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKEM4435Medicaid