Provider Demographics
NPI:1710076567
Name:DY, PHILIP A (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:DY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 W. MCKINLEY AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:DDECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-876-6600
Mailing Address - Fax:217-876-6606
Practice Address - Street 1:905 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401
Practice Address - Country:US
Practice Address - Phone:217-342-2066
Practice Address - Fax:217-342-2074
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097243207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097243Medicaid
0970490001Medicare NSC
L63915Medicare PIN
ILG72932Medicare UPIN
G72932Medicare UPIN