Provider Demographics
NPI:1558462382
Name:PHILLIPS, ANDREA L (MC)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-6235
Mailing Address - Country:US
Mailing Address - Phone:601-969-1756
Mailing Address - Fax:
Practice Address - Street 1:909 WESTLAND SVC DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209
Practice Address - Country:US
Practice Address - Phone:601-948-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS080003368Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
MSF28033Medicare UPIN