Healthcare Provider Details

I. General information

NPI: 1174627491
Provider Name (Legal Business Name): MARK DAVID PHILLIPS MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4924 CAMPBELL BLVD STE 200
BALTIMORE MD
21236
US

IV. Provider business mailing address

9910 FRANKLIN SQUARE DR # 2110
BALTIMORE MD
21236-4902
US

V. Phone/Fax

Practice location:
  • Phone: 443-442-2300
  • Fax: 410-367-2035
Mailing address:
  • Phone: 410-933-5412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD55495
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: