Provider Demographics
NPI:1821027756
Name:JACQUELINE PHILLIPS DPM INC
Entity Type:Organization
Organization Name:JACQUELINE PHILLIPS DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001422213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480H232340OtherBCBS PIN
MI134313228Medicaid
MIT96946Medicare UPIN
MI4703600001Medicare NSC
MI0P36510Medicare PIN