Basic Information
| Provider Information | |||||||||
| NPI: | 1386612257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILIPPS | ||||||||
| FirstName: | CONSTANCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8007 EXCELSIOR DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295238 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 REGENT ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082828270 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 42004 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 32626200 | 05 | WI | MEDICAID |