Healthcare Provider Details

I. General information

NPI: 1750815841
Provider Name (Legal Business Name): JUSTIN THOMAS PHILIP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 WALNUT HILL LN TEXAS HEALTH PRESBYTERIAN HOSPITAL DALLAS
DALLAS TX
75231-4426
US

IV. Provider business mailing address

8200 WALNUT HILL LN TEXAS HEALTH PRESBYTERIAN HOSPITAL DALLAS
DALLAS TX
75231-4426
US

V. Phone/Fax

Practice location:
  • Phone: 214-345-6789
  • Fax:
Mailing address:
  • Phone: 214-345-6789
  • 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 State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberT6675
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: