Provider Demographics
NPI:1780633230
Name:PHILLIPS, BRENDA M (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1302
Mailing Address - Country:US
Mailing Address - Phone:518-563-5440
Mailing Address - Fax:518-563-1206
Practice Address - Street 1:154 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1302
Practice Address - Country:US
Practice Address - Phone:518-563-5440
Practice Address - Fax:518-563-1206
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185388207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01243645Medicaid
NY01243645Medicaid
NY01243645Medicaid