Provider Demographics
NPI:1467620401
Name:JASON PHILLIPS M D P A
Entity Type:Organization
Organization Name:JASON PHILLIPS M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-693-9375
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-0519
Mailing Address - Country:US
Mailing Address - Phone:903-693-9375
Mailing Address - Fax:903-694-4654
Practice Address - Street 1:1410 W PANOLA ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-2348
Practice Address - Country:US
Practice Address - Phone:903-693-9375
Practice Address - Fax:903-694-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151901901Medicaid
TX00700TMedicare PIN
TX151901901Medicaid