Healthcare Provider Details

I. General information

NPI: 1669411245
Provider Name (Legal Business Name): STEPHEN A PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 S MAIN ST
UPLAND IN
46989-9242
US

IV. Provider business mailing address

221 N CELIA AVE ATTN: DEBERA BARKER RCS
MUNCIE IN
47303-4609
US

V. Phone/Fax

Practice location:
  • Phone: 765-998-6200
  • Fax: 765-998-6204
Mailing address:
  • Phone: 765-282-8905
  • Fax: 317-968-1047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01028159
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: