MEDICARE: PHILLIPS FAMILY HEALTHCARE, LLC

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	363LF0000X	Family Nurse Practitioner	A003572	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043527336	OTHER		PROVIDER'S NPI NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629457254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILLIPS FAMILY HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	2921 HWY 77 S
Second Line	:	SUITES 12-13
City	:	MARION
State	:	AR
Zip	:	72364-2367
Country	:	US
Telephone Number	:	901-438-8451
Fax Number	:

Provider Business Practice Location Address
First Line	:	2921 HWY 77 S
Second Line	:	SUITES 12-13
City	:	MARION
State	:	AR
Zip	:	72364-2367
Country	:	US
Telephone Number	:	901-438-8451
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRACTITIONER
Name	:	TED PHILLIPS
Credential	:	APRN
Telephone Number	:	901-438-8451

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	05/28/2015

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