Provider Demographics
NPI:1851378020
Name:ECKER, PHILLIP M (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:M
Last Name:ECKER
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 1:1905 WAYZATA BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-5006
Mailing Address - Country:US
Mailing Address - Phone:952-222-8149
Mailing Address - Fax:262-240-6257
Practice Address - Street 1:1905 WAYZATA BLVD STE 240
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-5006
Practice Address - Country:US
Practice Address - Phone:952-222-8149
Practice Address - Fax:262-240-6257
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47896207N00000X
AZ36316207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ166235Medicaid
MN059266800Medicaid
AZZ112854Medicare PIN
MN070000708Medicare ID - Type Unspecified
MN059266800Medicaid