Provider Demographics
NPI:1578547766
Name:PHILLIPS, MINTA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MINTA
Middle Name:ELIZABETH
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1317 N ELM STREET
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1023
Mailing Address - Country:US
Mailing Address - Phone:336-274-9617
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:1317 N ELM ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1023
Practice Address - Country:US
Practice Address - Phone:336-274-9617
Practice Address - Fax:336-482-2177
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC341282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC73484OtherMEDCOST
NC24728OtherPARTNERS
NC1600768OtherUNITED HEALTHCARE
NC8967664Medicaid
NC300085688OtherRAILROAD MEDICARE
NC67664OtherBLUE CROSS BLUE SHIELD
NC8967664Medicaid
NC300085688OtherRAILROAD MEDICARE