Provider Demographics
NPI:1639330533
Name:VAN, PHILLIP LEE (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LEE
Last Name:VAN
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GRANT ST FL 58
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15219-2739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 GRANT ST FL 58
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15219-2739
Practice Address - Country:US
Practice Address - Phone:412-647-4054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116020239207R00000X
MDD755392085B0100X
MA2423552085B0100X
WV273692085R0202X
MN718192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging