Provider Demographics
NPI:1255398715
Name:MASKALL, PHILIP ALEXANDER (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALEXANDER
Last Name:MASKALL
Suffix:
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 1:9632 S BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1338
Mailing Address - Country:US
Mailing Address - Phone:773-981-4851
Mailing Address - Fax:
Practice Address - Street 1:3623 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3934
Practice Address - Country:US
Practice Address - Phone:773-722-6171
Practice Address - Fax:773-722-7913
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067283Medicaid
IL910070Medicare ID - Type Unspecified
IL036067283Medicaid