MEDICARE: KELLY M. MCPHILLIPS M.D.

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	207Q00000X	Family Medicine Physician	57.029951	OH
2	390200000X	Student in an Organized Health Care Education/Training Program

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528593894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY M. MCPHILLIPS M.D.

Provider Business Mailing Address
First Line	:	2500 METROHEALTH DR
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44109-1900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	29804 LAKE SHORE BLVD
Second Line	:
City	:	WILLOWICK
State	:	OH
Zip	:	44095-4611
Country	:	US
Telephone Number	:	440-833-2095
Fax Number	:	440-833-2096

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

Provider Enumeration Date	:	04/25/2017
Last Update Date	:	03/08/2022

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