Basic Information
| Provider Information | |||||||||
| NPI: | 1588125751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DONNELL | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | JAMES MCILHENNY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 306 E 96TH ST APT 5G | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101283852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402231954 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 PELHAM PKWY S | ||||||||
| Address2: | BUILDING 6//SUITE B125 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104611138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189185820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NY | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.