Provider Demographics
NPI:1891291563
Name:PERSINO, PHILIP RICHARD
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:RICHARD
Last Name:PERSINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N EDDY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-3096
Mailing Address - Country:US
Mailing Address - Phone:574-204-6522
Mailing Address - Fax:
Practice Address - Street 1:6301 UNIVERSITY COMMONS STE 360
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-3500
Practice Address - Country:US
Practice Address - Phone:574-204-6522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01089151A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology