Provider Demographics
NPI:1881946952
Name:PHILLIP, DERICK (MD)
Entity type:Individual
Prefix:DR
First Name:DERICK
Middle Name:
Last Name:PHILLIP
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 999
Mailing Address - Street 2:FEDERAL CORRECTIONAL COMPLEX
Mailing Address - City:BUTNER
Mailing Address - State:NC
Mailing Address - Zip Code:27509
Mailing Address - Country:US
Mailing Address - Phone:919-575-5000
Mailing Address - Fax:919-575-5061
Practice Address - Street 1:OLD OXFORD HIGHWAY 75 LSCI
Practice Address - Street 2:FEDERAL CORRECTIONAL COMPLEX
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509
Practice Address - Country:US
Practice Address - Phone:919-575-5000
Practice Address - Fax:919-575-5061
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037403E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine