Provider Demographics
NPI:1831267244
Name:MAC, PHILLIP F (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:F
Last Name:MAC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:1447 YORK RD STE 100
Practice Address - Street 2:KAISER PERMANENTE TOWSON MEDICAL CENTER
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6074
Practice Address - Country:US
Practice Address - Phone:410-339-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0053902207Q00000X
DCMD039774207Q00000X
VA0101230789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A43919Medicare UPIN
S88360UUMedicare ID - Type Unspecified