Basic Information
| Provider Information | |||||||||
| NPI: | 1720297294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILIPPE | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 JAMES SIMPSON JR WAY | ||||||||
| Address2: | STE 201 | ||||||||
| City: | COVINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410110801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596554111 | ||||||||
| FaxNumber: | 8596554815 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 JAMES SIMPSON JR WAY | ||||||||
| Address2: | STE 201 | ||||||||
| City: | COVINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410110801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596554111 | ||||||||
| FaxNumber: | 8596554815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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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 | 207Q00000X | 40853 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2775822 | 05 | OH | MEDICAID | 7100014640 | 05 | KY | MEDICAID |