Provider Demographics
NPI:1982638318
Name:PHILLIPS, KENNETH J JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:PHILLIPS
Suffix:JR
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:3003 W GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2042
Practice Address - Country:US
Practice Address - Phone:414-352-3100
Practice Address - Fax:414-247-4597
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40558207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00470795OtherRR MEDICARE
WI32492100Medicaid
WI01994-0215Medicare PIN
WI46236-0215Medicare PIN
WIP00470795OtherRR MEDICARE