Provider Demographics
NPI:1114994316
Name:PHILLIPS, JEFFREY MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MARTIN
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 1:4501 OLD SPARTANBURG RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-4105
Mailing Address - Country:US
Mailing Address - Phone:864-292-8868
Mailing Address - Fax:864-268-9564
Practice Address - Street 1:4501 OLD SPARTANBURG RD
Practice Address - Street 2:SUITE 9
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4105
Practice Address - Country:US
Practice Address - Phone:864-292-8868
Practice Address - Fax:864-268-9564
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30363208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC303638Medicaid
GA111804539BMedicaid
NC5902675Medicaid
H82513Medicare UPIN