Provider Demographics
NPI:1598031601
Name:MICHAEL PHILLIPS MD LLC
Entity Type:Organization
Organization Name:MICHAEL PHILLIPS MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-553-7745
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2010
Mailing Address - Country:US
Mailing Address - Phone:417-553-7745
Mailing Address - Fax:417-553-7747
Practice Address - Street 1:1 MT CARMEL WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-7587
Practice Address - Country:US
Practice Address - Phone:417-553-7745
Practice Address - Fax:417-553-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-35567208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty