Provider Demographics
NPI:1932445012
Name:MICHAEL D PHILLIPS, MD MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MICHAEL D PHILLIPS, MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-701-9497
Mailing Address - Street 1:2560 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2998
Mailing Address - Country:US
Mailing Address - Phone:213-383-0007
Mailing Address - Fax:866-505-1544
Practice Address - Street 1:2560 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2998
Practice Address - Country:US
Practice Address - Phone:213-383-0007
Practice Address - Fax:866-505-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32413207P00000X, 207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA272AMedicare PIN