Healthcare Provider Details

I. General information

NPI: 1275819443
Provider Name (Legal Business Name): LUCAS PHILLIPS MED, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E 17TH ST
BLOOMINGTON IN
47408-1590
US

IV. Provider business mailing address

155 MIAMI ST
TIFFIN OH
44883-2109
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-7916
  • Fax:
Mailing address:
  • Phone: 419-448-3480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001524A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number3982
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: