Provider Demographics
NPI:1619172947
Name:PHILLIPS, MATHEW TODD (MD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:TODD
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 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-817-3599
Mailing Address - Fax:
Practice Address - Street 1:8620 BIGGIN HILL LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4117
Practice Address - Country:US
Practice Address - Phone:859-817-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036143518207X00000X
OH35127665207X00000X
KY43615207XS0117X, 207X00000X
IN01067795A207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY201028740OtherMEDICAID INDIANA
KY50033377OtherPASSPORT ADVANTAGE
IL036143518Medicaid
KY1840079OtherCIGNA
KYP00966208OtherRR MEDICARE
KY000000719168OtherANTHEM
IN300071320Medicaid
KY7100123040Medicaid
KY9854581OtherAETNA
KYP00966208OtherRR MEDICARE
KYK007482Medicare PIN
IN201028740 (JPG)Medicaid
KY50033377OtherPASSPORT ADVANTAGE
KY201028740OtherMEDICAID INDIANA
KY1840079OtherCIGNA
KYK007481 (JPG)Medicare PIN