Healthcare Provider Details

I. General information

NPI: 1104821222
Provider Name (Legal Business Name): GLENN STEPHEN MCPHILLIPS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 OFFICE PARK CIR
SELMA AL
36701-6506
US

IV. Provider business mailing address

6 OFFICE PARK CIR
SELMA AL
36701-6506
US

V. Phone/Fax

Practice location:
  • Phone: 334-872-5636
  • Fax: 334-872-5199
Mailing address:
  • Phone: 334-872-5636
  • Fax: 334-872-5199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number248
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: