Provider Demographics
NPI:1477562379
Name:PHILLIPS, KIMBERLY YOUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:YOUNG
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:142 HOSPITAL PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-8502
Mailing Address - Country:US
Mailing Address - Phone:706-485-1145
Mailing Address - Fax:706-485-6025
Practice Address - Street 1:142 HOSPITAL PERIMETER RD
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-8502
Practice Address - Country:US
Practice Address - Phone:706-485-1145
Practice Address - Fax:706-485-6025
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051711207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00322240OtherRAILROAD MEDICARE
GA051711OtherLICENSE NUMBER
GA000954786CMedicaid
GA20-2256065OtherFEDERAL TAX ID
GADE8801OtherRAILROAD MEDICARE
GA20-2256065OtherFEDERAL TAX ID
GA051711OtherLICENSE NUMBER