Healthcare Provider Details

I. General information

NPI: 1225094055
Provider Name (Legal Business Name): PHILIP A DAUTERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LOWER NAVY HILL ROAD
SAIPAN MP
96950
US

IV. Provider business mailing address

1 LOWER NAVY HILL ROAD
SAIPAN MP
96950
US

V. Phone/Fax

Practice location:
  • Phone: 670-234-8950
  • Fax: 670-236-8612
Mailing address:
  • Phone: 670-234-8950
  • Fax: 670-236-8612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberM-1177
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberM-1177
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: