Provider Demographics
NPI:1275568735
Name:PHILLIPS, MARK C (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:C
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:860 N MYRTLE RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97457-9626
Mailing Address - Country:US
Mailing Address - Phone:541-863-3410
Mailing Address - Fax:541-863-6435
Practice Address - Street 1:860 N MYRTLE RD
Practice Address - Street 2:
Practice Address - City:MYRTLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97457-9626
Practice Address - Country:US
Practice Address - Phone:541-863-3410
Practice Address - Fax:541-863-6435
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18731173000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR065586Medicaid
ORMD18731OtherSTATE LICENSE #
ORMD18731OtherSTATE LICENSE #
OR065586Medicaid
ORR0000BKTBQMedicare ID - Type UnspecifiedMEDICARE #