Healthcare Provider Details

I. General information

NPI: 1710407002
Provider Name (Legal Business Name): BROCK A PHILLIPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E PLUMMER BLVD STE A
CHATHAM IL
62629-8136
US

IV. Provider business mailing address

125 E PLUMMER BLVD STE A
CHATHAM IL
62629-8136
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6006
  • Fax:
Mailing address:
  • Phone: 314-454-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036152530
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: