Provider Demographics
NPI:1376865816
Name:PHILLIP STATES, MD, FAMILY PRACTICE
Entity Type:Organization
Organization Name:PHILLIP STATES, MD, FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:STATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-938-3550
Mailing Address - Street 1:81 HILLCREST DR
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2605
Mailing Address - Country:US
Mailing Address - Phone:814-938-3550
Mailing Address - Fax:814-938-3679
Practice Address - Street 1:81 HILLCREST DR
Practice Address - Street 2:SUITE 1300
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2605
Practice Address - Country:US
Practice Address - Phone:814-938-3550
Practice Address - Fax:814-938-3679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA393918261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA393918OtherCMS CERTIFICATION NUMBER
PA1019257860003Medicaid