Provider Demographics
NPI:1811181910
Name:PHILLIP, MICHAEL LAWRENCE (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:PHILLIP
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 N SHERMAN ST
Mailing Address - Street 2:#206
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-2909
Mailing Address - Country:US
Mailing Address - Phone:561-715-1515
Mailing Address - Fax:
Practice Address - Street 1:600 S 21ST ST
Practice Address - Street 2:SUITE 120
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3762
Practice Address - Country:US
Practice Address - Phone:719-634-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015934225100000X
COPTL.0012369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL568150OtherMEDICARE GROUP NUMBER
IL1619908OtherBCBS IL GROUP
ILCD3789OtherMEDICARE RAILROAD GROUP NUMBER
IL567700OtherMEDICARE GROUP NUMBER
ILP00624023OtherMEDICARE RAILROAD
IL568080OtherMEDICARE GROUP NUMBER
IL568150OtherMEDICARE GROUP NUMBER
IL568080OtherMEDICARE GROUP NUMBER
ILK45716Medicare PIN