=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659759652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP MICHAEL O'CONNOR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2015
-----------------------------------------------------
Last Update Date | 06/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1240 WESTLAWN DR
-----------------------------------------------------
City | KANKAKEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60901-4657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-693-7568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1240 WESTLAWN DR
-----------------------------------------------------
City | KANKAKEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60901-4657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-693-7568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | MT212023
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 036152000
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------