Provider Demographics
NPI:1558790691
Name:PHIPPS, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 PICKETT RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17315-3125
Mailing Address - Country:US
Mailing Address - Phone:717-292-6690
Mailing Address - Fax:
Practice Address - Street 1:50 WYNTRE BROOKE DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4535
Practice Address - Country:US
Practice Address - Phone:717-812-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG002348302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization