Provider Demographics
NPI:1942234554
Name:PHILLIPS, MICHAEL STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEPHEN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1301 W 7TH ST
Mailing Address - Street 2:SUITE # 121
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-2651
Mailing Address - Country:US
Mailing Address - Phone:817-348-0425
Mailing Address - Fax:817-748-0455
Practice Address - Street 1:1301 W 7TH ST
Practice Address - Street 2:SUITE # 121
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-2651
Practice Address - Country:US
Practice Address - Phone:817-348-0425
Practice Address - Fax:817-748-0425
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4598207Q00000X, 207Q00000X, 207QG0300X
TXE 4598207VG0400X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPOQD231Medicaid
TXPOQD231Medicaid