Provider Demographics
NPI:1598064636
Name:PHILLIPS, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6045 CARLISLE LN
Mailing Address - Street 2:6045 CARLISLE LN
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-6281
Mailing Address - Country:US
Mailing Address - Phone:770-379-1101
Mailing Address - Fax:
Practice Address - Street 1:6045 CARLISLE LN
Practice Address - Street 2:6045 CARLISLE LN
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-6281
Practice Address - Country:US
Practice Address - Phone:770-379-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59582207Q00000X
CAAFE29567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine