Provider Demographics
NPI:1821124728
Name:PHILLIPS, MARK T (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 749215
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9215
Mailing Address - Country:US
Mailing Address - Phone:901-226-3186
Mailing Address - Fax:
Practice Address - Street 1:1600 22ND AVE
Practice Address - Street 2:MEDICAL TOWERS III, 3RD FLOOR
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3223
Practice Address - Country:US
Practice Address - Phone:601-693-1055
Practice Address - Fax:601-482-5312
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2024-10-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS11068208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0110336Medicaid
MS0110336Medicaid
MS302I346460Medicare PIN