Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | 44214-020 | WI |
NPI | 1003808676 |
---|---|
Provider Name | Dr. Benjamin E Phillips |
First Address | Green Bay, WI 54303-2728 |
Second Address | Green Bay, WI 54303-2728 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/08/2005 |
Last Update Date | 19/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0376640002 | ADMINASTAR FEDERAL (01) | WI |
34181000 | (05) | WI |
H66576 | (02) | WI |