Provider Demographics
NPI:1659493542
Name:BRUCE W PHILLIPS MD PA
Entity Type:Organization
Organization Name:BRUCE W PHILLIPS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-347-8001
Mailing Address - Street 1:5800 NW 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-3478
Mailing Address - Country:US
Mailing Address - Phone:561-347-8001
Mailing Address - Fax:561-347-8015
Practice Address - Street 1:3651 FAU BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6489
Practice Address - Country:US
Practice Address - Phone:561-347-8001
Practice Address - Fax:561-347-8015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050838174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61001Medicare UPIN
FL03999ZMedicare ID - Type Unspecified