Provider Demographics
NPI:1538138748
Name:PHILLIPS, KENNETH P (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:P
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 1:7 BLANCHARD CIR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-2039
Mailing Address - Country:US
Mailing Address - Phone:630-653-2300
Mailing Address - Fax:
Practice Address - Street 1:7 BLANCHARD CIR
Practice Address - Street 2:SUITE 201
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-2039
Practice Address - Country:US
Practice Address - Phone:630-653-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360627722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062772Medicaid
IL02215643OtherBLUE CROSS BLUE SHIELD
ILCA2795OtherMEDICARE RAILROAD GROUP
ILCA2795OtherMEDICARE RAILROAD GROUP
ILL79033Medicare PIN
ILB74499Medicare UPIN