Provider Demographics
NPI:1093791246
Name:STATES, PHILLIP JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JOHN
Last Name:STATES
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 1:83 HILLCREST DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2605
Mailing Address - Country:US
Mailing Address - Phone:814-938-3550
Mailing Address - Fax:814-938-3679
Practice Address - Street 1:83 HILLCREST DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2605
Practice Address - Country:US
Practice Address - Phone:814-938-3550
Practice Address - Fax:814-938-3679
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010451800001Medicaid
PA1641714OtherHIGHMARK BLUE SHIELD
PA1030096480002Medicaid
PA081510Medicare PIN
PA1010451800001Medicaid