Basic Information
| Provider Information | |||||||||
| NPI: | 1114930476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 570 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142934925 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2050 KENNY RD | ||||||||
| Address2: | SUITE 2200 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142934925 | ||||||||
| FaxNumber: | 6142935503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 35058205 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207RP1001X | 35058205 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0823863 | 05 | OH | MEDICAID |