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General NPI Number Information
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NPI Number | 1891159745
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Entity Type | Individual
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Provider Name | PHILLIPS CAO
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Gender | Male
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Dates
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Enumeration Date | 04/07/2016
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Last Update Date | 06/18/2019
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Provider Practice Location Address
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Address Line | 450077 STATE ROAD 200 STE 12
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City | CALLAHAN
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State | FL
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Zip | 32011-3863
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Country | US
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Telephone | 904-633-0561
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Fax | 315-801-3565
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Provider Business Mailing Address
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Address Line | 120 HOBART ST
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City | UTICA
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State | NY
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Zip | 13501-4308
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Country | US
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Telephone | 315-801-1149
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Fax | 315-801-3565
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME140356
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License Number State | FL
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