Provider Demographics
NPI:1508946112
Name:PHILIP ZUMWALT,M.D.
Entity Type:Organization
Organization Name:PHILIP ZUMWALT,M.D.
Other - Org Name:WATSEKA FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:ZUMWALT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-432-5430
Mailing Address - Street 1:125 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1601
Mailing Address - Country:US
Mailing Address - Phone:815-432-5430
Mailing Address - Fax:815-432-6024
Practice Address - Street 1:125 S 4TH ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1601
Practice Address - Country:US
Practice Address - Phone:815-432-5430
Practice Address - Fax:815-432-6024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL========= 001Medicaid
IL========= 001Medicaid