MEDICARE: MR. PHILLIP MARTIN HERRING II

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	164W00000X	Licensed Practical Nurse	043111308	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1578644431	OTHER	FL	BAY PINES VA HEALTH CARE SYSTEMS

General Provider Information

NPI Number	:	1205358843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILLIP MARTIN HERRING II

Provider Business Mailing Address
First Line	:	11258 WINDSOR PLACE CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-2688
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11258 WINDSOR PLACE CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-2688
Country	:	US
Telephone Number	:	773-669-4821
Fax Number	:

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

Provider Enumeration Date	:	07/15/2017
Last Update Date	:	07/15/2017

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