Basic Information
| Provider Information | |||||||||
| NPI: | 1528040367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MEDICAL DOCTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 PARK AVE BLDG D | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356158822 | ||||||||
| FaxNumber: | 4356158823 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 PARK AVE BLDG D | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356158822 | ||||||||
| FaxNumber: | 4356158823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 10/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | ME54865 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2000016351 | 01 | FL | RAILROAD MEDICARE | OTHER | 4511587 | 01 | FL | AETNA | OTHER | AVMED | 01 | FL | 258113 | OTHER | 18987 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 373524900 | 05 | FL | MEDICAID |