Provider Demographics
NPI:1710938725
Name:PHILLIPS, THEODORE GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:GEORGE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-402-6890
Practice Address - Fax:610-402-6892
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041580L208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000637659OtherKEYSTONE EAST
PA50039540OtherCAPITAL BLUE CROSS
PA637659OtherHIGHMARK BLUE SHIELD
PA637659OtherKEYSTONE CENTRAL
PA0012385870005Medicaid
PA1511814OtherGATEWAY HEALTH PLAN
PA35920OtherGEISINGER HEALTH PLAN
PAP00192724OtherRAILROAD MEDICARE
PA0467898000OtherAMERIHEALTH (IBC)
PA20034834OtherAMERIHEALTH MERCY
PA30022212OtherKEYSTONE MERCY
PA3641356OtherAETNA
PAP00192724OtherRAILROAD MEDICARE
PA50039540OtherCAPITAL BLUE CROSS