Provider Demographics
NPI:1043232580
Name:MINTZ, PHILIP G (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:G
Last Name:MINTZ
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:8970 WINCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125
Practice Address - Country:US
Practice Address - Phone:901-794-5806
Practice Address - Fax:901-794-7922
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13053207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3186539Medicaid
TNB04251Medicare UPIN
TN3735224Medicare ID - Type UnspecifiedGROUP PRICING NUMBER
3186591Medicare PIN
B04251Medicare UPIN