Healthcare Provider Details

I. General information

NPI: 1891934634
Provider Name (Legal Business Name): MARK A PHILIPS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 MCHENRY ST
BURLINGTON WI
53105-1828
US

IV. Provider business mailing address

252 MCHENRY ST
BURLINGTON WI
53105-1828
US

V. Phone/Fax

Practice location:
  • Phone: 262-767-6100
  • Fax: 262-767-6098
Mailing address:
  • Phone: 262-767-6100
  • Fax: 262-767-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036122532
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number53736
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: