Provider Demographics
NPI:1922024009
Name:PHILLIPS, EDYTH DARLENE (MD)
Entity Type:Individual
Prefix:
First Name:EDYTH
Middle Name:DARLENE
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:P.O. BOX 2
Mailing Address - Street 2:3200 78TH AVE. S.E.
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040
Mailing Address - Country:US
Mailing Address - Phone:206-232-7218
Mailing Address - Fax:206-232-8017
Practice Address - Street 1:3200 78TH AVE. S.E.
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040
Practice Address - Country:US
Practice Address - Phone:206-232-7218
Practice Address - Fax:206-232-8017
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000090642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1904309Medicaid
0102864OtherL & I
000104164Medicare ID - Type Unspecified
A05369Medicare UPIN