Healthcare Provider Details

I. General information

NPI: 1720425192
Provider Name (Legal Business Name): DAVID RYAN PHILLIPS MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2013
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W 13TH ST STE 325
JASPER IN
47546-1857
US

IV. Provider business mailing address

721 W 13TH ST STE 325
JASPER IN
47546-1857
US

V. Phone/Fax

Practice location:
  • Phone: 812-996-5575
  • Fax:
Mailing address:
  • Phone: 812-996-5575
  • Fax: 812-996-5580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01079657A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: