Provider Demographics
NPI:1821050568
Name:THERESA S. PHILLIPS, MD, PA
Entity Type:Organization
Organization Name:THERESA S. PHILLIPS, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-257-1785
Mailing Address - Street 1:PO BOX 293279
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78029-3279
Mailing Address - Country:US
Mailing Address - Phone:830-257-1785
Mailing Address - Fax:830-257-1786
Practice Address - Street 1:710 WATER ST
Practice Address - Street 2:#602
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5329
Practice Address - Country:US
Practice Address - Phone:830-257-1785
Practice Address - Fax:830-257-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ87142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113481903Medicaid
TX00390LMedicare ID - Type Unspecified
TX113481903Medicaid