Provider Demographics
NPI:1023080207
Name:MICHAEL JAY PHILLIPS, MD, SC
Entity type:Organization
Organization Name:MICHAEL JAY PHILLIPS, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-523-1245
Mailing Address - Street 1:1239 CORPORATE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4898
Mailing Address - Country:US
Mailing Address - Phone:262-569-8346
Mailing Address - Fax:
Practice Address - Street 1:1239 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4898
Practice Address - Country:US
Practice Address - Phone:262-569-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21295800Medicaid
WI21295800Medicaid