Provider Demographics
NPI:1255357612
Name:HAN, PHYLLIS H (MD)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:H
Last Name:HAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S MILWAUKEE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3199
Mailing Address - Country:US
Mailing Address - Phone:847-362-2900
Mailing Address - Fax:
Practice Address - Street 1:801 S MILWAUKEE RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3199
Practice Address - Country:US
Practice Address - Phone:847-362-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360830622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360830622Medicaid
C44560Medicare UPIN
ILL88081Medicare ID - Type Unspecified