Basic Information
| Provider Information | |||||||||
| NPI: | 1295943884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILIP | ||||||||
| FirstName: | ANCIL | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845833 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900845833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107923914 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2251 W ROSECRANS AVE STE 21 | ||||||||
| Address2: | |||||||||
| City: | COMPTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902223860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4245296755 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 54417-20 | WI | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | A147208 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1295943884 | 05 | WI | MEDICAID | PHILIANC | 01 | WI | MERCYCARE INSURANCE | OTHER | 1295943884 | 01 | WI | BCBSWI | OTHER |