Provider Demographics
NPI:1023017548
Name:PHILLIPS, CHARLES BAILEY JR (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BAILEY
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5039
Mailing Address - Country:US
Mailing Address - Phone:478-475-4131
Mailing Address - Fax:478-475-4128
Practice Address - Street 1:4045 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5039
Practice Address - Country:US
Practice Address - Phone:478-475-4131
Practice Address - Fax:478-475-4128
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
35ZCGSMMedicare ID - Type Unspecified
U89544Medicare UPIN