Basic Information
Provider Information
NPI: 1003802349
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PHILLIPS
FirstName: MARTIN
MiddleName: T
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 901 MCCLINTOCK DR
Address2: SUITE 202
City: BURR RIDGE
State: IL
PostalCode: 605270844
CountryCode: US
TelephoneNumber: 8882206432
FaxNumber: 6306544253
Practice Location
Address1: 555 W COURT ST
Address2: SUITE 108
City: KANKAKEE
State: IL
PostalCode: 609013664
CountryCode: US
TelephoneNumber: 8882206432
FaxNumber: 6306544253
Other Information
ProviderEnumerationDate: 09/22/2005
LastUpdateDate: 04/18/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RI0200X036-104648ILY Allopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease

ID Information
IDTypeStateIssuerDescription
042030705IA MEDICAID
036-104-64805IL MEDICAID


Home