Healthcare Provider Details

I. General information

NPI: 1790731412
Provider Name (Legal Business Name): JOHN GORDON PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE B-400
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-4368
  • Fax: 864-454-4348
Mailing address:
  • Phone: 864-797-6303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number15939
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: