Provider Demographics
NPI:1689970535
Name:PHILLIPS, MICHAEL G (SUB IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:SUB IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 LAS BRISAS ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-5014
Mailing Address - Country:US
Mailing Address - Phone:559-362-4304
Mailing Address - Fax:
Practice Address - Street 1:2621 LAS BRISAS ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-5014
Practice Address - Country:US
Practice Address - Phone:559-362-4304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman