Provider Demographics
NPI:1063180909
Name:PHILP, MATTHEW ALEXANDER (CCP, BS,)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ALEXANDER
Last Name:PHILP
Suffix:
Gender:M
Credentials:CCP, BS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16028 EAGLE RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-6812
Mailing Address - Country:US
Mailing Address - Phone:305-367-3582
Mailing Address - Fax:
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
149010242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
149010Other149010