Basic Information
| Provider Information | |||||||||
| NPI: | 1326097288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITHNELL | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1302 W MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446411114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308755544 | ||||||||
| FaxNumber: | 3308758150 | ||||||||
| Practice Location | |||||||||
| Address1: | 1302 W MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446411114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308755544 | ||||||||
| FaxNumber: | 3308758150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35071544 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2070226 | 05 | OH | MEDICAID |