Basic Information
| Provider Information | |||||||||
| NPI: | 1568474377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALVORSEN | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | ROY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 GAGE BLVD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099423627 | ||||||||
| FaxNumber: | 5099422268 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 STEVENS DR | ||||||||
| Address2: | SUITE 3A | ||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993523525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099468696 | ||||||||
| FaxNumber: | 5099468646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 11/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | MD00025724 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1013452 | 05 | WA | MEDICAID | 1568474377 | 01 | WA | NPI | OTHER | 1120732 | 05 | WA | MEDICAID |