Basic Information
Provider Information | |||||||||
NPI: | 1053334797 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAYLOR | ||||||||
FirstName: | PHILIP | ||||||||
MiddleName: | W | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., FACP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 843225 | ||||||||
Address2: |   | ||||||||
City: | KANSAS CITY | ||||||||
State: | MO | ||||||||
PostalCode: | 641843225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7086331234 | ||||||||
FaxNumber: | 7083427100 | ||||||||
Practice Location | |||||||||
Address1: | 3250 GORDONVILLE RD | ||||||||
Address2: | STE 301 | ||||||||
City: | CAPE GIRARDEAU | ||||||||
State: | MO | ||||||||
PostalCode: | 637035056 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733349641 | ||||||||
FaxNumber: | 5733313120 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 05/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | R5645 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 1053334797 | 05 | IL |   | MEDICAID | 603522 | 01 | MO | ANTHEM BCBS | OTHER | 173594 | 01 |   | HEALTHLINK | OTHER | 201877826 | 05 | MO |   | MEDICAID | P00779931 | 01 | MO | RR MCR | OTHER |