Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 3982 | OH |
Y | 213ES0000X | Sports Medicine | 3982 | OH |
NPI | 1275819443 |
---|---|
Provider Name | Lucas Phillips |
First Address | Tiffin, OH 44883-2109 |
Second Address | Bloomington, IN 47408-1590 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2011 |
Last Update Date | 27/03/2018 |