Provider Demographics
NPI:1922049600
Name:PHILLIPS, ROGER ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ALAN
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 1:270 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3719
Mailing Address - Country:US
Mailing Address - Phone:616-396-2972
Mailing Address - Fax:616-396-2808
Practice Address - Street 1:270 HOOVER BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3719
Practice Address - Country:US
Practice Address - Phone:616-396-2972
Practice Address - Fax:616-396-2808
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047365207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1739680Medicaid
MI1739680Medicaid
MI23-1546Medicare ID - Type Unspecified