Provider Demographics
NPI:1639386303
Name:PHILLIPS, JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
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 1:48 TUNNEL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3875
Mailing Address - Country:US
Mailing Address - Phone:570-624-4777
Mailing Address - Fax:570-624-4778
Practice Address - Street 1:48 TUNNEL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3875
Practice Address - Country:US
Practice Address - Phone:570-624-4777
Practice Address - Fax:570-624-4778
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432171207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102721560001Medicaid
PA223382L50Medicare UPIN
PA223382JPUMedicare PIN