Provider Demographics
NPI:1962481044
Name:PHILLIPS, PAMELA KIM (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:KIM
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 1:4513 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-1302
Mailing Address - Country:US
Mailing Address - Phone:512-930-3909
Mailing Address - Fax:512-869-5868
Practice Address - Street 1:2805 5TH ST
Practice Address - Street 2:100
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7306
Practice Address - Country:US
Practice Address - Phone:605-755-5700
Practice Address - Fax:605-755-3691
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS4216207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN473987600Medicaid
E86565Medicare UPIN
MN070013602Medicare ID - Type UnspecifiedRAILROAD
MN070000522Medicare ID - Type Unspecified