Provider Demographics
NPI:1275511966
Name:PHILLIPS, MARK LUCAS (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LUCAS
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:522 N ELAM AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1151
Mailing Address - Country:US
Mailing Address - Phone:336-852-8444
Mailing Address - Fax:336-852-8401
Practice Address - Street 1:522 N ELAM AVE
Practice Address - Street 2:STE 203
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1151
Practice Address - Country:US
Practice Address - Phone:336-852-8444
Practice Address - Fax:336-852-8401
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC25639208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC720000034OtherRR MEDICARE
NC99475OtherMEDCOST
NC67625OtherBLUE CROSS BLUE SHIELD
NC17619OtherPARTNERS
NC2007829OtherUNITED HEALTHCARE
NC8967625Medicaid
IL371987800OtherUSDOL
VA5703760OtherVA MCD
NC720000034OtherRR MEDICARE
NC209571GMedicare PIN