Provider Demographics
NPI:1316018450
Name:PHILLIPS, ALEKSANDRA PANOV (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEKSANDRA
Middle Name:PANOV
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18121 PATRIOT WAY
Mailing Address - Street 2:
Mailing Address - City:WEST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02817-6023
Mailing Address - Country:US
Mailing Address - Phone:808-729-4301
Mailing Address - Fax:
Practice Address - Street 1:75 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4960
Practice Address - Country:US
Practice Address - Phone:508-923-5429
Practice Address - Fax:617-495-8078
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14781R2084P0800X, 2084P0804X
RIMD141442084P0800X
MA2773542084P0804X
HIMD115992084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1573761Medicaid
LA4E943Medicare ID - Type Unspecified
LAH63719Medicare UPIN