Provider Demographics
NPI:1750657821
Name:JACQUELINE PHILLIPS DPM INC
Entity Type:Organization
Organization Name:JACQUELINE PHILLIPS DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-345-4449
Mailing Address - Street 1:5575 CONNER ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-6400
Mailing Address - Country:US
Mailing Address - Phone:313-345-4449
Mailing Address - Fax:313-499-8341
Practice Address - Street 1:5575 CONNER ST
Practice Address - Street 2:SUITE 203
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-6400
Practice Address - Country:US
Practice Address - Phone:313-345-4449
Practice Address - Fax:313-499-8341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACQUELINE PHILLIPS DPM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001422332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1255320495Medicaid