MEDICARE: DR. PHILLIP IM CHIR 007185

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIR007185	GA

General Provider Information

NPI Number	:	1174745517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILLIP IM CHIR 007185

Provider Business Mailing Address
First Line	:	2645 N BERKELEY LAKE ROAD
Second Line	:	D-126
City	:	DULUTH
State	:	GA
Zip	:	30096
Country	:	US
Telephone Number	:	678-571-7140
Fax Number	:	470-709-2187

Provider Business Practice Location Address
First Line	:	2645 N BERKELEY LAKE RD NW # D-126
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3002
Country	:	US
Telephone Number	:	678-571-7140
Fax Number	:	470-709-2187

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/21/2022

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