Healthcare Provider Details

I. General information

NPI: 1962474064
Provider Name (Legal Business Name): AMANDA RUTH PHILLIPS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 W CONGRESS ST
LAFAYETTE LA
70506-4205
US

IV. Provider business mailing address

2390 W CONGRESS ST
LAFAYETTE LA
70506-4205
US

V. Phone/Fax

Practice location:
  • Phone: 337-261-6010
  • Fax: 337-261-6153
Mailing address:
  • Phone: 337-261-6010
  • Fax: 337-261-6153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number025853
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: