Provider Demographics
NPI:1629066170
Name:ZUMWALT, PHILIP FRANK (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:FRANK
Last Name:ZUMWALT
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 1:125 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1673
Mailing Address - Country:US
Mailing Address - Phone:815-432-5430
Mailing Address - Fax:815-432-6024
Practice Address - Street 1:125 S 4TH ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1673
Practice Address - Country:US
Practice Address - Phone:815-432-5430
Practice Address - Fax:815-432-6024
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054820Medicaid
IL143939OtherRURAL HEALTH CLINIC ID#
IL371163481OtherFED TAX ID #
IL3800066OtherBC/BS ID#
IL143939OtherRURAL HEALTH CLINIC ID#
IL036054820Medicaid