Provider Demographics
NPI:1275554669
Name:PHILLIPS, BRADFORD G (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:G
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 CURTIS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRYANT POND
Mailing Address - State:ME
Mailing Address - Zip Code:04219-6538
Mailing Address - Country:US
Mailing Address - Phone:207-674-3862
Mailing Address - Fax:
Practice Address - Street 1:431 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2100
Practice Address - Country:US
Practice Address - Phone:207-369-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA 132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPI5440Medicare UPIN