Provider Demographics
NPI:1003997271
Name:MARK B PHILLIPS M.D., P.A.
Entity Type:Organization
Organization Name:MARK B PHILLIPS M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-396-5558
Mailing Address - Street 1:PO BOX 10543
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-0543
Mailing Address - Country:US
Mailing Address - Phone:904-396-5558
Mailing Address - Fax:904-396-4279
Practice Address - Street 1:4545 EMERSON EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-399-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0047040207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8674Medicare ID - Type UnspecifiedGROUP MEDICARE