Provider Demographics
NPI:1003808676
Name:PHILLIPS, BENJAMIN E (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:E
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:1111 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5548
Practice Address - Country:US
Practice Address - Phone:920-684-4429
Practice Address - Fax:920-684-6892
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44214-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34181000Medicaid
WI0376640002OtherADMINASTAR FEDERAL
WI34181000Medicaid
WI0376640002OtherADMINASTAR FEDERAL
WI180045134Medicare PIN