Provider Demographics
NPI:1619075637
Name:EISENBERG, PHILLIP S (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:S
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 E TRAVERSE HWY STE 4400
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1320
Mailing Address - Country:US
Mailing Address - Phone:231-346-6800
Mailing Address - Fax:
Practice Address - Street 1:1000 PAVILLIONS CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-932-3000
Practice Address - Fax:231-932-3719
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010790207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4282710Medicaid
MI0Q26421Medicare ID - Type Unspecified
MI4282710Medicaid