Provider Demographics
NPI:1629287677
Name:PORCELLI, PHILLIP MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:PORCELLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-752-2305
Mailing Address - Fax:937-522-7513
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:SUITE 5350
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1264
Practice Address - Country:US
Practice Address - Phone:937-643-9299
Practice Address - Fax:937-643-2343
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ILBB0454912(81)207T00000X
OH34010246207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050529Medicaid
OHH009210Medicare PIN