MEDICARE: MARK STEPHEN PHILLIPS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-08167	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	397730042	OTHER	NC	NSC#

General Provider Information

NPI Number	:	1336633106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK STEPHEN PHILLIPS PA-C

Provider Business Mailing Address
First Line	:	645 N MAIN ST
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27260-5017
Country	:	US
Telephone Number	:	336-883-0029
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 KIMEL FOREST DR STE 100
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6084
Country	:	US
Telephone Number	:	336-883-0029
Fax Number	:	336-283-6518

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	03/07/2025

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