Provider Demographics
NPI:1255411187
Name:PHILLIPS, JOHN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:PHILLIPS
Suffix:
Gender:
Credentials:MD
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Mailing Address - Street 1:PO BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:1 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-598-4800
Practice Address - Fax:304-293-6963
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV205572080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV7088G274OtherMEDICARE HEARTNEXUS, INC.
WV0184366000Medicaid
WVPH6030471OtherMEDICARE
H43556Medicare UPIN