=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437135134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC A PHILLIPS D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 09/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 BALTANE RD
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48323-3100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-464-0887
-----------------------------------------------------
Fax | 734-402-0254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4967 CROOKS RD STE 130
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48098-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-952-1601
-----------------------------------------------------
Fax | 248-952-1614
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101007871
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------