Provider Demographics
NPI:1932635042
Name:PHILLIPS, MICHAEL (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 HAZEN ST
Mailing Address - Street 2:STE. C
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-2008
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-6523
Practice Address - Street 1:801 HAZEN ST
Practice Address - Street 2:STE. C
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-2008
Practice Address - Country:US
Practice Address - Phone:269-657-5574
Practice Address - Fax:269-657-6523
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704173621163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse