Provider Demographics
NPI:1841526944
Name:PHILLIPS, PUSHPA (MD)
Entity type:Individual
Prefix:DR
First Name:PUSHPA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5256
Mailing Address - Country:US
Mailing Address - Phone:770-720-7733
Mailing Address - Fax:770-720-7557
Practice Address - Street 1:227 RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5256
Practice Address - Country:US
Practice Address - Phone:770-720-7733
Practice Address - Fax:770-720-7557
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01980207V00000X
390200000X
GA86654207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCG058AMedicare PIN