Basic Information
| Provider Information | |||||||||
| NPI: | 1629287677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORCELLI | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377522305 | ||||||||
| FaxNumber: | 9375227513 | ||||||||
| Practice Location | |||||||||
| Address1: | 3533 SOUTHERN BLVD | ||||||||
| Address2: | SUITE 5350 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376439299 | ||||||||
| FaxNumber: | 9376432343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 09/25/2014 | ||||||||
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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 | 207T00000X | BB0454912(81) | IL | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 34010246 | OH | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0050529 | 05 | OH | MEDICAID |