Healthcare Provider Details

I. General information

NPI: 1134133523
Provider Name (Legal Business Name): JERRY DAVID PHILLIPS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1518 MILULI AVE
BAINBRIDGE GA
39819-4866
US

IV. Provider business mailing address

1518 MILULI AVE
BAINBRIDGE GA
39819-4866
US

V. Phone/Fax

Practice location:
  • Phone: 229-248-8500
  • Fax: 229-248-8600
Mailing address:
  • Phone: 229-248-8500
  • Fax: 229-248-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042107
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number042107
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: