Provider Demographics
NPI:1578544995
Name:PHILLIPS, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRADHURST AVE STE 3100N
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2140
Mailing Address - Country:US
Mailing Address - Phone:914-909-9018
Mailing Address - Fax:914-909-9028
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:BIMC DEPT OF UROLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-844-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2282231208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02419845Medicaid
NY0053N1Medicare ID - Type Unspecified
NY02419845Medicaid