Healthcare Provider Details

I. General information

NPI: 1063771087
Provider Name (Legal Business Name): NICOLE ALEXIS PHILLIPS MD (6/12)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 STONEGATE PARK STE 300
SAINT JOSEPH MI
49085-9136
US

IV. Provider business mailing address

75 FRANCIS ST
BOSTON MA
02115-6110
US

V. Phone/Fax

Practice location:
  • Phone: 269-556-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301502412
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: