Provider Demographics
NPI:1477747582
Name:PHILLIPS, JUSTIN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
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:P.O. BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:2 ST. VINCENT CIRCLE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5423
Practice Address - Country:US
Practice Address - Phone:501-552-3000
Practice Address - Fax:501-552-4181
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5814207P00000X
TXP6061207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01198742OtherMEDICARE RAILROAD
AR180290001Medicaid
TX317651301Medicaid
AR1477747582OtherBCBS
TX317651302Medicaid
TX317651303Medicaid
TX283265YKN5Medicare PIN
TX283265YLLVMedicare PIN
AR1477747582OtherBCBS
AR180290001Medicaid
TX317651301Medicaid