Provider Demographics
NPI:1316571359
Name:PHILLIPS, RICHARD (LMT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4998 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-8314
Mailing Address - Country:US
Mailing Address - Phone:937-830-5707
Mailing Address - Fax:
Practice Address - Street 1:5 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1326
Practice Address - Country:US
Practice Address - Phone:937-890-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center