Provider Demographics
NPI:1316792500
Name:PHILLIPS, EBONY ROXANNE
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:ROXANNE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E ERIE ST STE 525-2055
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2740
Mailing Address - Country:US
Mailing Address - Phone:773-603-2276
Mailing Address - Fax:
Practice Address - Street 1:1 E ERIE ST STE 525-2055
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2740
Practice Address - Country:US
Practice Address - Phone:773-603-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier