Provider Demographics
NPI:1407631468
Name:PHILLIPS, MARK SR (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:PHILLIPS
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4586 VALLEY PKWY SE UNITE E
Mailing Address - Street 2:4586 VALLEY PKWY SE UNIT E
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082
Mailing Address - Country:US
Mailing Address - Phone:914-943-1442
Mailing Address - Fax:
Practice Address - Street 1:4586 VALLEY PKWY SE UNITE E
Practice Address - Street 2:4586 VALLEY PKWY SE UNIT E
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082
Practice Address - Country:US
Practice Address - Phone:914-943-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty