Healthcare Provider Details

I. General information

NPI: 1669484713
Provider Name (Legal Business Name): DAVID PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 GATEWAY DR
SYCAMORE IL
60178-3192
US

IV. Provider business mailing address

1850 GATEWAY DR
SYCAMORE IL
60178-3192
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8671
  • Fax: 815-758-5610
Mailing address:
  • Phone: 815-758-8671
  • Fax: 815-758-5610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-084642
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: