Healthcare Provider Details

I. General information

NPI: 1275568735
Provider Name (Legal Business Name): MARK C PHILLIPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARK C PHILLIPS MD

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 N MYRTLE RD
MYRTLE CREEK OR
97457-9626
US

IV. Provider business mailing address

860 N MYRTLE RD
MYRTLE CREEK OR
97457-9626
US

V. Phone/Fax

Practice location:
  • Phone: 541-863-3410
  • Fax: 541-863-6435
Mailing address:
  • Phone: 541-863-3410
  • Fax: 541-863-6435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMD18731
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD18731
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier065586
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
IdentifierMD18731
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerSTATE LICENSE #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: