Provider Demographics
NPI:1831453158
Name:SANDIFER, PHILLIP ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ANTHONY
Last Name:SANDIFER
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 1:1211 S GLOSTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6548
Mailing Address - Country:US
Mailing Address - Phone:662-767-4200
Mailing Address - Fax:662-767-4204
Practice Address - Street 1:100 BAPTIST MEMORIAL CIR STE 330
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4477
Practice Address - Country:US
Practice Address - Phone:662-767-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25801207X00000X
UT10277685-1205207XS0114X
MST-2600207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04526240Medicaid