=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871028597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUSTIN PHILLIPS MD, A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2017
-----------------------------------------------------
Last Update Date | 05/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1107 FAIR OAKS AVE UNIT 465
-----------------------------------------------------
City | SOUTH PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91030-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-710-3810
-----------------------------------------------------
Fax | 626-270-4410
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1107 FAIR OAKS AVE UNIT 465
-----------------------------------------------------
City | SOUTH PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91030-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-710-3810
-----------------------------------------------------
Fax | 626-270-4410
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JUSTIN R PHILLIPS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 626-710-3810
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | A86090
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------