Provider Demographics
NPI:1275412157
Name:PHILLIPS, JOHN MICHAEL
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 10TH ST
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-2216
Mailing Address - Country:US
Mailing Address - Phone:681-393-3569
Mailing Address - Fax:
Practice Address - Street 1:1312 10TH ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-2216
Practice Address - Country:US
Practice Address - Phone:681-393-3569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant