Provider Demographics
NPI:1700015773
Name:JUSTICE, PHILLIP E (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:E
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 HIGHLAND GLEN CT
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4595
Mailing Address - Country:US
Mailing Address - Phone:865-385-9743
Mailing Address - Fax:
Practice Address - Street 1:1700 PINEBROOK DR
Practice Address - Street 2:STE. 2
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4365
Practice Address - Country:US
Practice Address - Phone:423-245-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23692084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528770Medicaid
TN103I137463Medicare PIN
TN1528770Medicaid
NCNCJ219D540Medicare PIN