Provider Demographics
NPI:1801980149
Name:PHILLIPS, MARTIN R (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:R
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:PO BOX 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:333 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5334
Practice Address - Country:US
Practice Address - Phone:401-728-1300
Practice Address - Fax:401-723-0978
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05527208G00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI700184Medicaid
RID87333Medicare UPIN
RI029005105Medicare PIN
RI007058888Medicare PIN
RI700184Medicaid