Provider Demographics
NPI:1831131762
Name:PHILLIPS, VICTOR M (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 W EDGEWOOD DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6891
Mailing Address - Country:US
Mailing Address - Phone:573-632-0010
Mailing Address - Fax:573-632-2449
Practice Address - Street 1:3308 W. EDGEWOOD DR.
Practice Address - Street 2:SUITE D
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6891
Practice Address - Country:US
Practice Address - Phone:573-632-0010
Practice Address - Fax:573-632-2449
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030144707208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207627308Medicaid
MO542244OtherHEALTHLINK
MOCD6061OtherRAILROAD GROUP
MO205098OtherBCBS
MOP00307873OtherMEDICARE RAILROAD
MOP00307873OtherMEDICARE RAILROAD
MO542244OtherHEALTHLINK
MOH58020Medicare UPIN