Provider Demographics
NPI:1871584383
Name:PHILLIPS, JOHN B (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:B
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 1:50 SKYLINE LN
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-2345
Mailing Address - Country:US
Mailing Address - Phone:731-847-6373
Mailing Address - Fax:731-847-6579
Practice Address - Street 1:50 SKYLINE LN
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-2345
Practice Address - Country:US
Practice Address - Phone:731-847-6373
Practice Address - Fax:731-847-6579
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000010756207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3176892Medicaid
TN4404OtherBLUE CROSS
TN3176892Medicaid
3176895Medicare PIN