Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0100X | Gastroenterologist | 14911 | MS |
NPI | 1023077732 |
---|---|
Provider Name | John O Phillips |
First Address | Tupelo, MS 38802-0021 |
Second Address | Tupelo, MS 38801-6301 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2006 |
Last Update Date | 25/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00116829 | (05) | MS |
E57960 | (02) | MS |