MEDICARE: MADISON JAMES PHILLIPS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1376328955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON JAMES PHILLIPS

Provider Business Mailing Address
First Line	:	412 E OKLAHOMA ST
Second Line	:
City	:	WALTERS
State	:	OK
Zip	:	73572-1622
Country	:	US
Telephone Number	:	580-559-6133
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 E OKLAHOMA ST
Second Line	:
City	:	WALTERS
State	:	OK
Zip	:	73572-1622
Country	:	US
Telephone Number	:	580-559-6133
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2023
Last Update Date	:	08/31/2023

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