MEDICARE: DR. KEITH A PHILLIPS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	01031573A	IN

General Provider Information

NPI Number	:	1417180308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH A PHILLIPS M.D.

Provider Business Mailing Address
First Line	:	1116 MILLIS AVE
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-2226
Country	:	US
Telephone Number	:	812-897-7130
Fax Number	:

Provider Business Practice Location Address
First Line	:	1116 MILLIS AVE
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-2226
Country	:	US
Telephone Number	:	812-897-7130
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2009
Last Update Date	:	08/26/2009

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