=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083242614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC IGNATIUS PHILIP MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2020
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3635 VISTA AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63110-2539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-577-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4431 CHOUTEAU AVE APT 1203
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63110-1607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-209-1324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 036164016
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------