Provider Demographics
NPI:1649201245
Name:TAYLOR, PHILIP (DO)
Entity Type:Individual
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First Name:PHILIP
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3152 PORT SHELDON ST
Practice Address - Street 2:SUITE C
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-9297
Practice Address - Country:US
Practice Address - Phone:616-669-9238
Practice Address - Fax:616-669-8296
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101009981207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2870886Medicaid
MI2870886Medicaid