Provider Demographics
NPI:1891081386
Name:PHILLIPS, CHRISTOPHER M (DPM)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44096-1086
Mailing Address - Country:US
Mailing Address - Phone:216-645-7242
Mailing Address - Fax:440-975-8278
Practice Address - Street 1:4520 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-3602
Practice Address - Country:US
Practice Address - Phone:651-426-3995
Practice Address - Fax:651-426-5626
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN923213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472603200Medicaid
MN7217560001Medicare NSC
MN472603200Medicaid