Provider Demographics
NPI:1871028597
Name:JUSTIN PHILLIPS MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JUSTIN PHILLIPS MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-710-3810
Mailing Address - Street 1:1107 FAIR OAKS AVE
Mailing Address - Street 2:UNIT 465
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3311
Mailing Address - Country:US
Mailing Address - Phone:626-710-3810
Mailing Address - Fax:626-270-4410
Practice Address - Street 1:1107 FAIR OAKS AVE
Practice Address - Street 2:UNIT 465
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3311
Practice Address - Country:US
Practice Address - Phone:626-710-3810
Practice Address - Fax:626-270-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86090208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty