Provider Demographics
NPI:1396722393
Name:PHILLIPS, STEPHEN W (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
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 1:6550 FANNIN ST
Mailing Address - Street 2:SM749
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-441-7465
Mailing Address - Fax:713-790-2996
Practice Address - Street 1:6550 FANNIN
Practice Address - Street 2:SM749
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-441-7465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN443792085R0202X
TXN10682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200189301Medicaid
MN031638500Medicaid
8BQ331OtherBLUE CROSS BLUE SHIELD
TX8F21043Medicare PIN
MN300126736Medicare ID - Type UnspecifiedRAILROAD
MN300002538Medicare ID - Type Unspecified
8BQ331OtherBLUE CROSS BLUE SHIELD
TX200189301Medicaid