Healthcare Provider Details

I. General information

NPI: 1225496235
Provider Name (Legal Business Name): PHILLIPS MED INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 CENTRAL AVE STE. 106
RIVERSIDE CA
92506-2933
US

IV. Provider business mailing address

4100 CENTRAL AVE STE. 106
RIVERSIDE CA
92506-2933
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA139283
License Number StateCA

VIII. Authorized Official

Name: PATRICK PHILLIPS
Title or Position: CEO
Credential: MD
Phone: 209-499-0090