Provider Demographics
NPI:1871633768
Name:PHILLIPS, DAN M (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:M
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:PO BOX 1811
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-1811
Mailing Address - Country:US
Mailing Address - Phone:336-330-0400
Mailing Address - Fax:
Practice Address - Street 1:3762 DURHAM RD
Practice Address - Street 2:STE A
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-2741
Practice Address - Country:US
Practice Address - Phone:336-330-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39060207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8967602Medicaid
2254643FMedicare ID - Type Unspecified
NC8967602Medicaid