Provider Demographics
NPI:1518372127
Name:PHILLIPS, CARSON
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2822 JACKSON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3497
Mailing Address - Country:US
Mailing Address - Phone:605-341-1208
Mailing Address - Fax:605-341-3552
Practice Address - Street 1:2822 JACKSON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3497
Practice Address - Country:US
Practice Address - Phone:605-341-1208
Practice Address - Fax:605-341-3552
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine