Provider Demographics
NPI:1245280056
Name:PHILLIPS, MICHAEL GAINES (MSN, ACNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GAINES
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MSN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CREEKVIEW COURT
Mailing Address - Street 2:SAME
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:864-627-4032
Mailing Address - Fax:864-627-4035
Practice Address - Street 1:27 CREEKVIEW CT
Practice Address - Street 2:SAME
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4800
Practice Address - Country:US
Practice Address - Phone:864-627-4032
Practice Address - Fax:864-627-4035
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC730363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
11854536OtherCAQH UNIVERSAL PROVIDER ID
11854536OtherCAQH UNIVERSAL PROVIDER ID