Provider Demographics
NPI:1497727671
Name:PHILLIPS, MICHAEL JAY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAY
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 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-635-3906
Mailing Address - Fax:252-224-0378
Practice Address - Street 1:701 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5239
Practice Address - Country:US
Practice Address - Phone:252-633-2081
Practice Address - Fax:252-633-3446
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36110208600000X
NC2013-00879208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32088700Medicaid
E99214Medicare UPIN