Provider Demographics
NPI:1356406599
Name:LOWE, PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:LOWE
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 12890
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-2890
Mailing Address - Country:US
Mailing Address - Phone:307-733-7460
Mailing Address - Fax:307-733-7482
Practice Address - Street 1:555 E BROADWAY
Practice Address - Street 2:SUITE 207
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-7460
Practice Address - Fax:307-733-7482
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6215A208800000X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806233600Medicaid
ID806684400Medicaid
WY118827500Medicaid
WY114954700Medicaid
WY340017838Medicare ID - Type UnspecifiedRAILROAD INDIVIDUAL#
WY118827500Medicaid
WYW9787Medicare ID - Type UnspecifiedGROUP#
WYW9788Medicare ID - Type UnspecifiedINDIVIDUAL#
ID806233600Medicaid
WY114954700Medicaid