Healthcare Provider Details

I. General information

NPI: 1366555328
Provider Name (Legal Business Name): EDWARD K. PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAKELAND SQUARE EXT STE B
FLOWOOD MS
39232-7607
US

IV. Provider business mailing address

40 VALLEY STREAM PKWY STE 100
MALVERN PA
19355-1407
US

V. Phone/Fax

Practice location:
  • Phone: 601-936-0890
  • Fax: 601-936-0891
Mailing address:
  • Phone: 610-644-8900
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number9170
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number09170
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: