Provider Demographics
NPI:1326070111
Name:PHILLIPS, JOHN G (M D)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-512-5100
Mailing Address - Fax:704-512-5101
Practice Address - Street 1:15110 JOHN J DELANEY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3545
Practice Address - Country:US
Practice Address - Phone:704-512-5100
Practice Address - Fax:704-512-5101
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11491207V00000X
NC28075207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7905171Medicaid
NC1326070111Medicaid
NC67621OtherNC BLUE CROSS BLUE SHIELD
SC114913Medicaid
NC8967621Medicaid
NC8967621Medicaid
SCC859827165Medicare PIN
NC209569CMedicare PIN
NC160055151Medicare PIN
NCNCK939AMedicare PIN
SC114913Medicaid