Provider Demographics
NPI:1528025095
Name:PHILLIPS, MAMIE L (MD)
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAMIE
Other - Middle Name:LEE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1247 DONALD LEE HOLLOWELL PKWY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318
Mailing Address - Country:US
Mailing Address - Phone:404-616-2265
Mailing Address - Fax:404-881-0622
Practice Address - Street 1:1247 DONALD LEE HOLLOWELL PKWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318
Practice Address - Country:US
Practice Address - Phone:404-616-2265
Practice Address - Fax:404-881-0622
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021338208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D40865Medicare UPIN