MEDICARE: MS. MARY CAROL PHILLIPS CRNP

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	363LA2200X	Adult Health Nurse Practitioner	TP003855B	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TP003855B	OTHER	PA	LICENCE

General Provider Information

NPI Number	:	1487684981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY CAROL PHILLIPS CRNP

Provider Business Mailing Address
First Line	:	180 1/2 HIGHVIEW DR
Second Line	:
City	:	UPPER ST CLAIR
State	:	PA
Zip	:	15241-1637
Country	:	US
Telephone Number	:	412-833-9808
Fax Number	:	724-250-7568

Provider Business Practice Location Address
First Line	:	100 RIDGE AVE
Second Line	:
City	:	WASHINGTON
State	:	PA
Zip	:	15301-3449
Country	:	US
Telephone Number	:	724-250-7790
Fax Number	:	724-250-7568

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/08/2007

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