Basic Information
| Provider Information | |||||||||
| NPI: | 1285151571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILIPP | ||||||||
| FirstName: | MEGAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6016 LOVERS LN | ||||||||
| Address2: | STE 3 | ||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490023050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155916590 | ||||||||
| FaxNumber: | 6155916601 | ||||||||
| Practice Location | |||||||||
| Address1: | 5886 VENTURE PARK DR | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490091848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
| FaxNumber: | 6163565001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2017 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11302 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5501018521 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0446631 | 05 | TN | MEDICAID |