Provider Demographics
NPI:1568568632
Name:PHILIP, SHAILAJA M (MD)
Entity Type:Individual
Prefix:
First Name:SHAILAJA
Middle Name:M
Last Name:PHILIP
Suffix:
Gender:F
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:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-4433
Mailing Address - Fax:682-885-3939
Practice Address - Street 1:712 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2703
Practice Address - Country:US
Practice Address - Phone:682-885-1024
Practice Address - Fax:682-885-1033
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0866208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX003GSOtherBCBSTX GRP PIN
TX175593601Medicaid
TX080626701Medicaid
TX16331401Medicaid
TX8B2076OtherBCBSTX IND PIN
1003887985OtherGRP NPI NUMBER
TX170994101Medicaid
TX7529393OtherAETNA PIN
TX175593602Medicaid
TX175593603Medicaid
TX8818814OtherCIGNA PIN
TXF67550OtherPRONET PIN
TX16331401Medicaid