Healthcare Provider Details

I. General information

NPI: 1619062106
Provider Name (Legal Business Name): ETHAN MICHAEL PHILPOTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 N. SCOTTSDALE ROAD
SCOTTSDALE AZ
85257
US

IV. Provider business mailing address

2255 N. SCOTTSDALE ROAD
SCOTTSDALE AZ
85257
US

V. Phone/Fax

Practice location:
  • Phone: 480-464-8000
  • Fax: 480-990-2556
Mailing address:
  • Phone: 480-464-8000
  • Fax: 480-990-2556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036127162
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: