Healthcare Provider Details

I. General information

NPI: 1891731055
Provider Name (Legal Business Name): PHILLIP H LUCAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 EAST SPRING STREET
COOKEVILLE TN
38501-3208
US

IV. Provider business mailing address

136 EAST SPRING STREET
COOKEVILLE TN
38501-3208
US

V. Phone/Fax

Practice location:
  • Phone: 931-854-1011
  • Fax: 931-854-1335
Mailing address:
  • Phone: 931-854-1011
  • Fax: 931-854-1335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number09840
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: