Provider Demographics
NPI:1942471842
Name:PHILLIPP MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:PHILLIPP MEDICAL GROUP, INC
Other - Org Name:PHILLIPP ALLERGY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:CONSTANTINA
Authorized Official - Last Name:PHILLIPP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-914-5803
Mailing Address - Street 1:130 W ROUTE 66
Mailing Address - Street 2:SUITE 220
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6249
Mailing Address - Country:US
Mailing Address - Phone:626-914-5803
Mailing Address - Fax:626-963-1569
Practice Address - Street 1:130 W ROUTE 66
Practice Address - Street 2:SUITE 220
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6249
Practice Address - Country:US
Practice Address - Phone:626-914-5803
Practice Address - Fax:626-963-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11704Medicare PIN