Healthcare Provider Details

I. General information

NPI: 1245798180
Provider Name (Legal Business Name): DR. BRADLEY PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

90 HOPE DR
MOUNTAIN HOME AFB ID
83648-1057
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7362
  • Fax: 208-828-1916
Mailing address:
  • Phone: 208-828-7362
  • Fax: 208-828-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101270994
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM-17656
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: