Provider Demographics
NPI:1487767018
Name:KIBORT, PHILLIP M (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:M
Last Name:KIBORT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2910 CENTRE POINTE DRIVE
Mailing Address - Street 2:35 121A CHILDRENS HEALTH CARE
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2327
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:347 NORTH SMITH AVENUE
Practice Address - Street 2:MAIL STOP 70 501 CHILDRENS HOSPITALS AND CLINICS OF MIN
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6165
Practice Address - Fax:651-220-5147
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN25027208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A95509Medicare UPIN