Provider Demographics
NPI:1841281995
Name:PHILLIPS, BENJAMIN R (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
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 1:1100 WALNUT ST
Mailing Address - Street 2:MOB, 5TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5563
Mailing Address - Country:US
Mailing Address - Phone:215-955-6750
Mailing Address - Fax:215-923-8222
Practice Address - Street 1:1100 WALNUT ST
Practice Address - Street 2:MOB, 5TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5563
Practice Address - Country:US
Practice Address - Phone:215-955-6750
Practice Address - Fax:215-923-8222
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01072208600000X
NJ25MA08649700208600000X
NJMA08649700208C00000X
PAMD433750208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901864Medicaid
NJMA08649700OtherSTATE LICENSE
NC2045946Medicare ID - Type Unspecified
NJMA08649700OtherSTATE LICENSE