Healthcare Provider Details

I. General information

NPI: 1295423200
Provider Name (Legal Business Name): JEREL ANTONIO PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 09/24/2026
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MORRIS PARK AVE. SUITE 615A
BRONX NY
10461-1900
US

IV. Provider business mailing address

2763 MORRIS AVE APT. 702
BRONX NY
10468
US

V. Phone/Fax

Practice location:
  • Phone: 718-430-2496
  • Fax:
Mailing address:
  • Phone: 929-309-7267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: