Provider Demographics
NPI:1073503462
Name:PHILLIPS, ALFRED MATTHEW (MD)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:MATTHEW
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 1:925 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-5178
Mailing Address - Country:US
Mailing Address - Phone:775-445-7800
Mailing Address - Fax:775-782-2967
Practice Address - Street 1:925 IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-5178
Practice Address - Country:US
Practice Address - Phone:775-445-7800
Practice Address - Fax:775-782-2967
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26253207P00000X, 207Q00000X
NV14369207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ632738Medicaid
NMW6787Medicaid
CO01262534Medicaid
320059Medicare Oscar/Certification
NMW6787Medicaid
D49901Medicare UPIN
8HZ29RMedicare PIN