Provider Demographics
NPI:1558349746
Name:PHILLIPS, WILLIAM WALTER (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALTER
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7870W HWY US2
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-1522
Mailing Address - Country:US
Mailing Address - Phone:906-341-2153
Mailing Address - Fax:906-341-3299
Practice Address - Street 1:7870W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-8992
Practice Address - Country:US
Practice Address - Phone:906-341-2153
Practice Address - Fax:906-341-3299
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007415207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4773255Medicaid
MI0G71004OtherRHC BLUE CROSS
MI74-2517055OtherSMH TAX ID NUMBER
MI74-2517055OtherSMH TAX ID NUMBER
MIA778321Medicare UPIN