Provider Demographics
NPI:1417919044
Name:PHILLIPS, MICHAEL JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEROME
Last Name:PHILLIPS
Suffix:
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:PO BOX 602522
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2522
Mailing Address - Country:US
Mailing Address - Phone:252-638-2515
Mailing Address - Fax:252-638-8538
Practice Address - Street 1:3110 WELLONS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5247
Practice Address - Country:US
Practice Address - Phone:252-638-2515
Practice Address - Fax:252-638-8538
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38408207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8967661Medicaid
NCB64974Medicare UPIN
NC8967661Medicaid