Healthcare Provider Details

I. General information

NPI: 1487619128
Provider Name (Legal Business Name): PHILIP MARK RALIDIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E 15TH ST
AUSTIN TX
78701-1930
US

IV. Provider business mailing address

3003 LOVELAND CV
AUSTIN TX
78746-7635
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberJ7147
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: