Healthcare Provider Details

I. General information

NPI: 1902891872
Provider Name (Legal Business Name): CHARLES M PHILLIPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 MOYE BLVD FL 3 ECU PHYSICIANS DERMATOLOGY
GREENVILLE NC
27834-2849
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-3109
  • Fax: 252-744-2096
Mailing address:
  • Phone: 252-744-3253
  • Fax: 252-744-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number30079
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: