Provider Demographics
NPI:1255366175
Name:PHILLIPS, THIRSTON S JR (DO)
Entity type:Individual
Prefix:MR
First Name:THIRSTON
Middle Name:S
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:DO
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 31166
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-0020
Mailing Address - Country:US
Mailing Address - Phone:910-495-6287
Mailing Address - Fax:910-222-3063
Practice Address - Street 1:100 WATER GRANDE BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-8162
Practice Address - Country:US
Practice Address - Phone:843-366-4000
Practice Address - Fax:910-222-3063
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400575208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC136YWOtherBLUE CROSS AND BLUE SHIEL
NC195400OtherMEDCOST PROVIDER ID
SCQ0057FMedicaid
NC89136YWMedicaid
NC612107500OtherOWCP PROVIDER ID
NC612107500OtherOWCP PROVIDER ID