Provider Demographics
NPI:1841782307
Name:FISH, PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:FISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N KEENE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8131
Mailing Address - Country:US
Mailing Address - Phone:573-499-4990
Mailing Address - Fax:573-442-2120
Practice Address - Street 1:105 N KEENE ST STE 201
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8131
Practice Address - Country:US
Practice Address - Phone:573-499-4990
Practice Address - Fax:573-442-2120
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X208800000X
MO2023012283208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology