Provider Demographics
NPI:1851322895
Name:PHILLIPS, MARIANA A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANA
Middle Name:A
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 1:1 RIVERSIDE CIR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 RIVERSIDE CIR
Practice Address - Street 2:SUITE 300
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4962
Practice Address - Country:US
Practice Address - Phone:540-581-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235823207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010187306Medicaid
VAP00459778OtherMEDICARE RAILROAD
VAP00459778OtherMEDICARE RAILROAD
VA541581185OtherEIN
VA008702M82 C03682Medicare ID - Type UnspecifiedCMS