Provider Demographics
NPI:1518960012
Name:MICKELSEN, PHILLIP LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LEE
Last Name:MICKELSEN
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 1:6420 56TH AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-0380
Mailing Address - Country:US
Mailing Address - Phone:308-224-2062
Mailing Address - Fax:888-974-5962
Practice Address - Street 1:6420 56TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-0380
Practice Address - Country:US
Practice Address - Phone:308-224-2062
Practice Address - Fax:888-974-5962
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107063207L00000X
NE32312207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM967331OtherPRONET / AETNA
NM43227252Medicaid
AZ859457Medicaid
NM86929Medicaid
MN107063OtherMN MEDICAL LICENSE
NMNM009R60OtherBLUE CROSS BLUE SHEILD
MN107063OtherMN MEDICAL LICENSE