Provider Demographics
NPI:1669411245
Name:PHILLIPS, STEPHEN A (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N CELIA AVE
Mailing Address - Street 2:ATTN: DEBERA BARKER RCS
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4609
Mailing Address - Country:US
Mailing Address - Phone:765-282-8905
Mailing Address - Fax:317-968-1047
Practice Address - Street 1:1809 S MAIN ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:IN
Practice Address - Zip Code:46989-9242
Practice Address - Country:US
Practice Address - Phone:765-998-6200
Practice Address - Fax:765-998-6204
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100173540Medicaid
P01071459OtherRAILROAD MEDICARE
INM400022684Medicare PIN
INC25312Medicare UPIN