Provider Demographics
NPI:1538120837
Name:PHILLIPS, JOHN RICHARD (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RICHARD
Last Name:PHILLIPS
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 1:13255 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-6245
Mailing Address - Country:US
Mailing Address - Phone:262-786-2875
Mailing Address - Fax:262-786-2096
Practice Address - Street 1:13255 W BLUEMOUND RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6245
Practice Address - Country:US
Practice Address - Phone:262-786-2875
Practice Address - Fax:262-786-2096
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17714207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31211900Medicaid
WI000368010OtherPTIN
B55734Medicare UPIN
WI68049Medicare ID - Type Unspecified
WI31211900Medicaid