Healthcare Provider Details

I. General information

NPI: 1467818484
Provider Name (Legal Business Name): ADAM PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 N BROADWAY ST
POTEAU OK
74953-2000
US

IV. Provider business mailing address

401 N CHURCH ST
POTEAU OK
74953-3502
US

V. Phone/Fax

Practice location:
  • Phone: 918-649-0018
  • Fax:
Mailing address:
  • Phone: 918-649-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10220
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: