Provider Demographics
NPI:1306396007
Name:PHILLIPS FAMILY MEDICINE CLINIC LLC
Entity Type:Organization
Organization Name:PHILLIPS FAMILY MEDICINE CLINIC LLC
Other - Org Name:G. SCOTT PHILLIPS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-382-9401
Mailing Address - Street 1:382 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIBLEY
Mailing Address - State:LA
Mailing Address - Zip Code:71073-2985
Mailing Address - Country:US
Mailing Address - Phone:318-382-9401
Mailing Address - Fax:
Practice Address - Street 1:382 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIBLEY
Practice Address - State:LA
Practice Address - Zip Code:71073-2985
Practice Address - Country:US
Practice Address - Phone:318-382-9401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1495344Medicaid
LA1495344Medicaid