Provider Demographics
NPI:1295943884
Name:PHILIP, ANCIL K (MD)
Entity type:Individual
Prefix:
First Name:ANCIL
Middle Name:K
Last Name:PHILIP
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:PO BOX 845833
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-5833
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:
Practice Address - Street 1:2251 W ROSECRANS AVE STE 21
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-3860
Practice Address - Country:US
Practice Address - Phone:424-529-6755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54417-20208600000X
CAA147208208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295943884Medicaid
WIPHILIANCOtherMERCYCARE INSURANCE
WI1295943884OtherBCBSWI
IL$$$$$$$$$ 1Medicaid
WI1295943884OtherBCBSWI