Provider Demographics
NPI:1952487076
Name:PHILLIPS, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:1000 PARK CENTRE BLVD
Mailing Address - Street 2:#138
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5373
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:
Practice Address - Street 1:19310 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-1562
Practice Address - Country:US
Practice Address - Phone:708-300-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F44189Medicare UPIN