Provider Demographics
NPI:1164497871
Name:PHILLIPS, WENDELL S (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:S
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-0150
Mailing Address - Country:US
Mailing Address - Phone:903-595-6680
Mailing Address - Fax:903-592-1934
Practice Address - Street 1:700 OLYMPIC PLAZA CIR STE 508
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1952
Practice Address - Country:US
Practice Address - Phone:903-595-6680
Practice Address - Fax:903-592-1934
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3395208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V9349OtherBCBS
TXP01101629OtherRR MEDICARE
TX330005911OtherRAILROAD MEDICARE
TX042415202Medicaid
TX8G4081OtherBLUECROSS BLUESHIELD TX
TX330005911OtherRAILROAD MEDICARE
TXP01101629OtherRR MEDICARE
TX8G4081OtherBLUECROSS BLUESHIELD TX