Provider Demographics
NPI:1760443600
Name:PHILLIPS, ROBERT MELVIN JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MELVIN
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29202 BRADMOOR CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3261
Mailing Address - Country:US
Mailing Address - Phone:248-901-5252
Mailing Address - Fax:
Practice Address - Street 1:35 SOUTH JOHNSON STREET
Practice Address - Street 2:SUITE 1B
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-334-9542
Practice Address - Fax:248-334-6792
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047298208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRP047298OtherBCBS
MI332609910Medicaid
MI104952354Medicaid
MI110636895OtherBLUECROSS SHIELD
MI0M92460026Medicare PIN
MI110636895OtherBLUECROSS SHIELD
MI104952354Medicaid