Provider Demographics
NPI:1871553917
Name:PHILLIPS, WESLEY F (MD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:F
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-595-3699
Mailing Address - Fax:336-595-3193
Practice Address - Street 1:2800 DARROW RD
Practice Address - Street 2:
Practice Address - City:WALKERTOWN
Practice Address - State:NC
Practice Address - Zip Code:27051-9206
Practice Address - Country:US
Practice Address - Phone:336-595-3699
Practice Address - Fax:336-595-3193
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8967675Medicaid
NC209573BMedicare ID - Type Unspecified
NC209573FMedicare PIN
NC8967675Medicaid