Provider Demographics
NPI:1134125420
Name:WELLS, PHILLIP KEVIN (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:KEVIN
Last Name:WELLS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1297
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-7297
Mailing Address - Country:US
Mailing Address - Phone:478-892-0530
Mailing Address - Fax:478-783-0802
Practice Address - Street 1:222 PERRY HWY
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-6748
Practice Address - Country:US
Practice Address - Phone:478-783-0200
Practice Address - Fax:478-783-0802
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052653207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA360737730AMedicaid
H90280Medicare UPIN
GA360737730AMedicaid