Provider Demographics
NPI:1659395903
Name:FALLT, PHILIP J (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:J
Last Name:FALLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1020 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2504
Mailing Address - Country:US
Mailing Address - Phone:612-302-8200
Mailing Address - Fax:612-302-8275
Practice Address - Street 1:1020 W BROADWAY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2504
Practice Address - Country:US
Practice Address - Phone:612-302-8200
Practice Address - Fax:612-302-8275
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN31855207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN349388100Medicaid
MND81761Medicare UPIN
MN349388100Medicaid