Provider Demographics
NPI:1710240510
Name:PHILLIPS, BRUCE (AA, BS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:AA, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 CRITTENTON PL
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2719
Mailing Address - Country:US
Mailing Address - Phone:410-467-2120
Mailing Address - Fax:
Practice Address - Street 1:2225 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5778
Practice Address - Country:US
Practice Address - Phone:410-366-4360
Practice Address - Fax:410-662-8547
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program