Provider Demographics
NPI:1962066597
Name:PHILLIPS, MATTHEW DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3717
Mailing Address - Country:US
Mailing Address - Phone:708-453-6800
Mailing Address - Fax:708-453-3235
Practice Address - Street 1:1950 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-3717
Practice Address - Country:US
Practice Address - Phone:708-453-6800
Practice Address - Fax:708-453-3235
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036171243208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36171243Medicaid