Provider Demographics
NPI:1013086040
Name:PHILLIPS, JIM JASON (MD)
Entity type:Individual
Prefix:DR
First Name:JIM
Middle Name:JASON
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:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-0519
Mailing Address - Country:US
Mailing Address - Phone:903-693-9375
Mailing Address - Fax:903-694-4654
Practice Address - Street 1:1410 W PANOLA ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-2348
Practice Address - Country:US
Practice Address - Phone:903-693-9375
Practice Address - Fax:903-694-4654
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG92256Medicare UPIN
TX8774B6Medicare PIN