Provider Demographics
NPI:1487205829
Name:PHILLIPS PEDIATRICS, LLC
Entity Type:Organization
Organization Name:PHILLIPS PEDIATRICS, LLC
Other - Org Name:PHILLIPS PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:DURST
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-371-1543
Mailing Address - Street 1:2682 W OXFORD LOOP STE 130
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5441
Mailing Address - Country:US
Mailing Address - Phone:662-371-1543
Mailing Address - Fax:662-371-1548
Practice Address - Street 1:2682 W OXFORD LOOP STE 130
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5441
Practice Address - Country:US
Practice Address - Phone:662-371-1543
Practice Address - Fax:662-371-1548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01224088Medicaid