Provider Demographics
NPI:1952491938
Name:PHILLIPS, BRUCE A (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DC
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 892
Mailing Address - Street 2:2200 NORTH STATE STREET
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-0892
Mailing Address - Country:US
Mailing Address - Phone:812-346-4181
Mailing Address - Fax:812-346-7217
Practice Address - Street 1:2200 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-0892
Practice Address - Country:US
Practice Address - Phone:812-346-4181
Practice Address - Fax:812-346-7217
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ-08001378A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100195200AMedicaid
IN000000089320Medicare UPIN
IN100195200AMedicaid