Provider Demographics
NPI:1952499659
Name:PHILLIPS, ALICE W (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:W
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:6210 JOHN RYAN DR
Practice Address - Street 2:STE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4113
Practice Address - Country:US
Practice Address - Phone:817-370-0840
Practice Address - Fax:817-370-8689
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7358208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137072806Medicaid
TX5187188OtherAETNA PIN
TX89W003OtherBCBSTX IND PIN
TX1392586OtherUHC PIN
TXPHIAG30706OtherCCHIP PIN
1750369203OtherGRP NPI NUMBER
TX7164413OtherCIGNA PIN
TX096374602Medicaid
TX1640300OtherFIRSTHEATLH PIN
TX018071301Medicaid
TX00U87ZOtherBCBSTX GRP PIN
TX096374602Medicaid
TX018071301Medicaid
TX00U87ZOtherBCBSTX GRP PIN