Provider Demographics
NPI:1518194067
Name:PHILLIPS, MARY-ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY-ANN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
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 763
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0763
Mailing Address - Country:US
Mailing Address - Phone:800-541-4009
Mailing Address - Fax:
Practice Address - Street 1:7 CHENOWETH DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1887
Practice Address - Country:US
Practice Address - Phone:304-842-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV24493208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program