Healthcare Provider Details

I. General information

NPI: 1831181403
Provider Name (Legal Business Name): ROBERT L. PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 PEACHTREE ST
JESUP GA
31545-0244
US

IV. Provider business mailing address

PO BOX 937
JESUP GA
31598-0937
US

V. Phone/Fax

Practice location:
  • Phone: 912-427-6964
  • Fax: 912-427-0591
Mailing address:
  • Phone: 912-427-6964
  • Fax: 912-427-0591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16826
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: