Provider Demographics
NPI:1063494375
Name:PHILLIPS, MARK G (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:300 BUTLER ST
Mailing Address - Street 2:PALM BEACH PATHOLOGY PA
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-6006
Mailing Address - Country:US
Mailing Address - Phone:561-659-0770
Mailing Address - Fax:561-802-3504
Practice Address - Street 1:2013 PONCE DELEON AVE
Practice Address - Street 2:PALM BEACH PATHOLOGY PA
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-6019
Practice Address - Country:US
Practice Address - Phone:561-659-0770
Practice Address - Fax:561-802-3504
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-08-27
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Provider Licenses
StateLicense IDTaxonomies
FLME55124207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
220011725OtherRAILROAD MEDICARE
FL057823100Medicaid
FL14419OtherBLUE CROSS BLUE SHIELD
FL057823100Medicaid
FL14419SMedicare PIN
FL14419VMedicare PIN
FL14419ZMedicare PIN
FLCR759ZMedicare PIN