Provider Demographics
NPI:1871688341
Name:PHILLIP, DERWIN A (MD)
Entity Type:Individual
Prefix:
First Name:DERWIN
Middle Name:A
Last Name:PHILLIP
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 1:1000 RIVER ROAD
Mailing Address - Street 2:STE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428
Mailing Address - Country:US
Mailing Address - Phone:800-355-3818
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:9000 FRANKLIN SQUARE DRIVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237
Practice Address - Country:US
Practice Address - Phone:877-202-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDXXXXXX207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD761L50KKMedicare PIN
H19512Medicare UPIN