Healthcare Provider Details

I. General information

NPI: 1932463312
Provider Name (Legal Business Name): SUSIE B PHILLIPS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-2940
  • Fax: 601-984-2926
Mailing address:
  • Phone: 601-984-2940
  • Fax: 601-984-2926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT-2592
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23466
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: