Healthcare Provider Details

I. General information

NPI: 1427051937
Provider Name (Legal Business Name): PAUL KENNETH PHILLIPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 HARRISON AVE
PANAMA CITY FL
32405-4542
US

IV. Provider business mailing address

1940 HARRISON AVE
PANAMA CITY FL
32405-4542
US

V. Phone/Fax

Practice location:
  • Phone: 850-763-0017
  • Fax: 850-532-6454
Mailing address:
  • Phone: 850-763-0017
  • Fax: 850-532-6454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01056981A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME117663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: