Provider Demographics
NPI:1871501411
Name:PHILLIPS, MATTHEW W (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:W
Last Name:PHILLIPS
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 1:340 OXFORD STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-1967
Mailing Address - Country:US
Mailing Address - Phone:330-364-8011
Mailing Address - Fax:330-364-0058
Practice Address - Street 1:340 OXFORD STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-1967
Practice Address - Country:US
Practice Address - Phone:330-364-8011
Practice Address - Fax:330-364-0058
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-052082174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341832667OtherSTANDARD TAX ID
OHI7880OtherRR GROUP
OH0697938Medicaid
OH020042125OtherRR MEDICARE
OH0646330OtherAETNA
OH000000139928OtherANTHEM
OH2080966Medicaid
OHI700421OtherUNITED HEALTHCARE IND
OH341832667AOtherAULTCARE
OH2080966Medicaid
OH0646330OtherAETNA