Provider Demographics
NPI:1104873579
Name:MASTERSON, PHILLIP J (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:J
Last Name:MASTERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3554 LOCH BEND DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4325
Mailing Address - Country:US
Mailing Address - Phone:248-363-2450
Mailing Address - Fax:
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:NOMC EMERGENCY CENTER
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7440
Practice Address - Fax:248-857-6992
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2012-01-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301406121207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104405849Medicaid
MI104405849Medicaid
MIB48085Medicare UPIN