Provider Demographics
NPI:1144388521
Name:PHILLIPS PEDIATRICS PC
Entity Type:Organization
Organization Name:PHILLIPS PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:O
Authorized Official - Last Name:AJAYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-876-6868
Mailing Address - Street 1:455 S MAIN STREET
Mailing Address - Street 2:STE 101
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-4354
Mailing Address - Country:US
Mailing Address - Phone:912-876-6868
Mailing Address - Fax:912-876-6566
Practice Address - Street 1:455 S MAIN STREET
Practice Address - Street 2:STE 101
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4354
Practice Address - Country:US
Practice Address - Phone:912-876-6868
Practice Address - Fax:912-876-6566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00936537AMedicaid
GA00936537AMedicaid
GA37BBGDVMedicare ID - Type Unspecified