Provider Demographics
NPI:1932169273
Name:GREENVILLE EAR NOSE & THROAT
Entity Type:Organization
Organization Name:GREENVILLE EAR NOSE & THROAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. JOHN GORDON PHILLIPS
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-454-4368
Mailing Address - Street 1:PO BOX 26569
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-1569
Mailing Address - Country:US
Mailing Address - Phone:864-454-4368
Mailing Address - Fax:864-454-4345
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:BUILDING B SUITE B400
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-4368
Practice Address - Fax:864-454-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15939261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCL5602OtherRAILROAD MEDICARE
SCGP0618Medicaid
SCGP0618Medicaid