Provider Demographics
NPI:1609160993
Name:PHILLIPS, LARA (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:HERSHCOVITCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1020 SANSOM ST
Mailing Address - Street 2:SUITE 239
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5002
Mailing Address - Country:US
Mailing Address - Phone:215-955-6844
Mailing Address - Fax:215-955-2526
Practice Address - Street 1:1020 SANSOM ST
Practice Address - Street 2:SUITE 239
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5002
Practice Address - Country:US
Practice Address - Phone:215-955-6844
Practice Address - Fax:215-955-2526
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD453744207P00000X
MA257774207P00000X
TNMD0000049128207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103039208 0001Medicaid
PA103039208 0002Medicaid
NJ0466581Medicaid
NJ0466581Medicaid