Healthcare Provider Details

I. General information

NPI: 1235526245
Provider Name (Legal Business Name): TERRY PHILLIPS JR. B.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17800 KEDZIE AVE
HAZEL CREST IL
60429-2029
US

IV. Provider business mailing address

1023 BURLINGTON AVE
WESTERN SPRINGS IL
60558-1516
US

V. Phone/Fax

Practice location:
  • Phone: 708-213-3825
  • Fax: 708-213-0132
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.023344
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: