Provider Demographics
NPI:1972793958
Name:PHILLIPPO, JOHN GREGORY (RPT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GREGORY
Last Name:PHILLIPPO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6742
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-6742
Mailing Address - Country:US
Mailing Address - Phone:231-633-8011
Mailing Address - Fax:231-995-0921
Practice Address - Street 1:325 W 8TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3103
Practice Address - Country:US
Practice Address - Phone:231-633-8011
Practice Address - Fax:231-995-0921
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501000866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOB85703OtherBLUE CROSS BLUE SHIELD OF
MIOB85703OtherBLUE CROSS BLUE SHIELD OF