Provider Demographics
NPI:1922165000
Name:MUCKSAVAGE, PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MUCKSAVAGE
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 1:299 SOUTH 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4010
Mailing Address - Country:US
Mailing Address - Phone:215-829-3409
Mailing Address - Fax:215-925-9749
Practice Address - Street 1:299 SOUTH 8TH STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4010
Practice Address - Country:US
Practice Address - Phone:215-829-3409
Practice Address - Fax:215-925-9749
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434333208800000X
PAMT184231208800000X
CAA109939208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA228489Medicare PIN