Healthcare Provider Details

I. General information

NPI: 1659759652
Provider Name (Legal Business Name): PHILLIP MICHAEL O'CONNOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 WESTLAWN DR
KANKAKEE IL
60901-4657
US

IV. Provider business mailing address

1240 WESTLAWN DR
KANKAKEE IL
60901-4657
US

V. Phone/Fax

Practice location:
  • Phone: 815-693-7568
  • Fax:
Mailing address:
  • Phone: 815-693-7568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMT212023
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036152000
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: