Healthcare Provider Details

I. General information

NPI: 1346225141
Provider Name (Legal Business Name): GRANT C PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 N LITCHFIELD RD
LUKE AFB AZ
85309-1529
US

IV. Provider business mailing address

37 W LYNWOOD ST
PHOENIX AZ
85003-1204
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-3279
  • Fax: 623-856-2210
Mailing address:
  • Phone: 602-462-5036
  • Fax: 623-856-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAZ28994
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: